The Final Diagnosis

Most nights of the week Dr. Joseph Pearson made a practice of going to bed early. Necessarily, though, on the evenings he played chess with Eustace Swayne he was much later - an occurrence which left him tired and more irritable than usual next morning. This effect, from last night's session, was with him now.

Working his way through purchase requisitions for lab supplies - a task he detested ordinarily and more than ever at this moment - he snorted and put one of the vouchers aside. He scribbled a few more signatures, then paused again and snatched a second voucher from the pile. This time there was a scowl as well as the snort. An ultimate would have known the danger signs - Dr. Pearson was ready to blow his top.

The moment came when he hesitated over a third voucher. Then, explosively, he threw his pencil down, grabbed up all the papers in an untidy heap, and made for the door. Storming into the serology lab, he looked around for Bannister. He found the senior technician in a corner preparing a stool culture.

"Drop whatever you're doing and come over here!" Pearson dumped the pile of papers on a center table. Several fell to the floor, and John Alexander bent down to retrieve them. He felt an instinctive relief that Bannister, and not himself, was the object of Dr. Pearson's anger.

"What's the trouble?" Bannister strolled across. He was so used to these outbursts that sometimes they had the effect of making him calmer.

"I'll tell you what's the trouble - it's all these purchase orders." Pearson himself was more subdued now, as if his ill temper was simmering instead of being on the boil. "Sometimes you seem to think we're running the Mayo Clinic."

"We gotta have lab supplies, haven't we?"

Ignoring the question, "There are times I wonder if you eat the stuff. And besides, didn't I tell you to put a note on anything out of the ordinary, explaining what it was for?"

"I guess I forgot." Bannister's tone was resigned.

"All right, you can start remembering." Pearson picked a form from the top of the pile. "What's the calcium oxide for? We never use that here."

Bannister's face creased in a malicious grin. "You asked me to get that. Isn't it for your garden?" The senior technician was referring to a fact which both of them knew but seldom spoke of. As one of the county horticultural society's leading rose growers, Joe Pearson absorbed a goodly quantity of hospital lab supplies in improving the growing power of his soil.

He had the grace to appear embarrassed. "Oh . . . yeah . . . okay, let that one go." He put down the voucher and picked up a second. "What about this one? Why do we want Coombs serum all of a sudden? Who ordered that?"

"It was Dr. Coleman." Bannister answered readily; this was a subject he had hoped would come up. Alongside him John Alexander had a sense of foreboding.

"When?" Pearson's question was sharp.

"Yesterday. Dr. Coleman signed the requisition anyway." Bannister pointed to the voucher, then added maliciously, "In the place where you usually sign."

Pearson glanced down at the form. Until now he had not noticed there was a signature on it. He asked Bannister, "What does he want it for? Do you know?"

The senior technician relaxed. He had set the wheels of retribution in motion and now he could enjoy this scene as a spectator. He told John Alexander, "Go ahead. Tell him."

A shade uneasily John Alexander said, "It's for a blood-sensitization test, Dr. Pearson. For my wife. Dr. Dornberger ordered it."

"Why Coombs serum?"

"It's for an indirect Coombs test, Doctor."

"Tell me - is there something special about your wife?" Pearson's voice had an edge of sarcasm. "What's wrong with the saline and high-protein tests? The same as we use for everybody else?"

Alexander swallowed nervously. There was a silence. Pearson said, "I'm waiting for an answer."

"Well, sir." Alexander hesitated, then blurted out, "I suggested to Dr. Coleman - and he agreed - it would be more reliable if, after the other tests, we did a - "

"You suggested to Dr. Coleman, eh?" The tone of the question left no doubt of what was about to happen. Sensing it, Alexander blundered on.

"Yes, sir. We felt that since some antibodies can't be detected in saline and high protein, running the extra test - "

"Cut it out!" The words were loud, harsh, brutal. As he said them Pearson slammed his hand hard down on the pile of forms and the table beneath. There was silence in the laboratory.

Breathing hard, the old man waited, eying Alexander. When he was ready he said grimly, "There's one big trouble with you - you're just a bit too free with some of that stuff you picked up in technician's school."

As Pearson spoke his bitterness came through - the bitterness against all who were younger, who were interfering, trying to deprive him of authority - absolute and unquestioned - which until now had been his. In a different mood, and at another time, he might have handled this more tolerantly. Now, coming as it did, he had plainly decided, once and for all, to put this upstart lab assistant in his place.

"Listen to me and get this straight! I told you this once before and I don't aim to do it again." This was Authority speaking, the head of a department, heavy-handed, making it clear to a minor employee that there would be no more warnings, merely action, from this point on. His face close to Alexander's, Pearson said, "I'm the one in charge of this department, and if you or anybody else have any queries, they come to me. Do you understand?"

"Yes, sir." At this instant all Alexander wanted was for this to end. He already knew he had made his last suggestion. If this was what you got for thinking, from here on he would do his work and keep his thoughts to himself. Let other people do the worrying - and let them have the responsibility too.

But Pearson had not finished. "Don't go running around behind my back," he said, "and taking advantage of Dr. Coleman because he's new."

Briefly Alexander's spirit flared. "I didn't take advantage . . ."

"And I say you did! And I'm telling you to cut it out!" The old man shouted angrily, his face muscles working, his eyes fiery.

Alexander stood, crushed and silent.

For a moment or two Pearson surveyed the younger man grimly. Then, as if satisfied that his point was made, he went on to speak again. "Now I'll tell you something else." His tone this time, if not cordial, was at least less harsh. "As far as that blood test is concerned, a test in saline and high protein will give us all the information we need. And let me remind you I happen to be a pathologist and I know what I'm talking about. Have you got that?"

Dully Alexander answered, "Yes, sir."

"All right. I'll tell you what I'll do." Pearson's voice became more moderate; it was almost as if he were offering a truce. "Since you're so keen on this test being right, I'll do it myself. Here and now. Where's the blood specimen?"

"In the refrigerator," Bannister said.

"Get it."

Crossing the lab, Bannister decided this scene had not turned out exactly the way he would have liked. It was true the Alexander kid had needed to be taken down a peg, but, all the same, the old man had laid it on the kid a bit hard. Bannister would have liked to see some of the storm move in the direction of that snide young doctor. But maybe the old man was saving that for later. He selected the blood specimen marked "Alexander, Mrs. E." and closed the refrigerator door.

Pearson took the blood sample, which already had the clot removed. As he did, Bannister noticed the purchase order which had been the cause of the trouble; it had fallen to the floor. He bent down and picked it up.

He asked Pearson, "What shall I do with this?"

The old pathologist had taken two clean test tubes. Now he was aspirating a portion of the blood serum into each. Without looking up he said irritably, "What is it?"

"It's the purchase requisition - for Coombs serum."

"We won't need it now. Tear it up." Pearson was scrutinizing the label of a small bottle containing Rh-positive cells. Prepared by a drug house, the solution was used as a reagent in testing Rh-negative blood.

Bannister hesitated. Much as he objected to Coleman, he knew there was a question of medical protocol involved. "You ought to let Dr. Coleman know," he said doubtfully. "Do you want me to tell him?"

Pearson was having trouble with the cork of the bottle. He said impatiently, "No, I'll tell him myself."

Bannister shrugged. He had pointed something out; if there were any trouble now, it would not be his responsibility. He took the purchase requisition and tore it up, allowing the pieces to flutter down into a wastebasket below.

Roger McNeil, the pathology resident, suspected that no matter how many years he stayed in medicine he would never become hardened to performing autopsies on children. He had just completed one, and now, in the autopsy room, the red-gaping body of the four-year-old boy lay open, pathetically, before him. The sight disturbed McNeil as much as ever. He knew, as always, there would be little sleep for him tonight. This scene would keep recurring in his mind - particularly when he remembered, as inevitably he would, how unnecessary and futile this particular death had been.

Looking up, he saw Mike Seddons watching him. The surgical resident said, "Poor little bastard." Then, bitterly, "How stupid can people get!"

McNeil asked, "Are the police still waiting?"

Seddons nodded. "Yes - and the others."

"You'd better call Pearson."

"All right." There was a telephone in the autopsy-room annex, and Seddons went to it.

McNeil wondered if he were being cowardly in avoiding this responsibility. But this was a case the old man should be told of anyway. Then he could make the decision on who would break the news outside this room.

Seddons had returned from the phone. "Pearson was in Serology," he said. "He's coming across now."

The two men waited silently. Then they heard Pearson's shuffling footsteps, and the old man came in. He glanced at the body as McNeil recited the details of the case. An hour or two earlier the child had been struck by an automobile outside his own home. He had been brought to the hospital by ambulance but was dead on arrival. Notified, the coroner had ordered an autopsy. McNeil told Pearson what they had discovered.

The old man said, "You mean that's all?" He seemed incredulous.

McNeil answered, "That's all that killed him. Nothing else."

Pearson moved toward the body, then stopped. He knew McNeil well enough to be aware that the resident would have made no mistake. He said, "Then they must have just stood there . . . and watched."

Seddons put in, "Most likely nobody knew what was happening."

Pearson nodded slowly. Seddons wondered what the old man was thinking. Then Pearson asked, "How old was the child?"

"Four," McNeil answered. "Nice-looking kid too."

All of them glanced at the autopsy table and the still, small figure. The eyes were closed, the fair, tousled hair pulled back in place now that the brain had been removed. Pearson shook his head, then turned toward the door. Over his shoulder he said, "All right; I'll go up and tell them."

The three occupants of the hospital anteroom looked up as Pearson entered. One was a uniformed patrolman of the city police, and near him was a tall man whose eyes were red-rimmed. The third occupant - dejected and sitting alone in the far corner - was a mousy little man with a straggling mustache.

Pearson introduced himself. The patrolman said, "I'm Stevens, sir. Fifth Precinct." He produced a notebook and pencil.

Pearson asked him, "Were you at the scene of the accident?"

"I arrived just after it happened." He indicated the tall man. "This is the father of the boy. The other gentleman was the driver of the car."

The mousy man looked up. Appealing to Pearson, he said, "He ran straight out - straight out from the side of the house. I'm not a careless driver. I've got kids of my own. I wasn't going fast. I was almost stopped when it happened."

"And I say you're a lousy liar." It was the father, his voice choked with emotion and bitterness. "You killed him, and I hope you go to jail for it."

Pearson said quietly, "Just a moment, please." There was silence, the others watching him. He motioned to the policeman's notebook. "There'll be a full report for the coroner, but I can tell you the preliminary findings now." He paused. "The autopsy has shown it was not the car that killed the boy."

The patrolman looked puzzled. The father said, "But I was there! I tell you . . ."

"I wish there were some other way to tell you this," Pearson said, "but I'm afraid there isn't." He addressed the father. "The blow your boy received knocked him to the road, and there was a mild concussion which rendered him unconscious. He also sustained a small fracture of the nose - quite minor, but unfortunately it caused his nose to bleed profusely." Pearson turned to the patrolman. "The boy was left lying on his back, I believe - where he fell."

The officer said, "Yes, sir, that's right. We didn't want to move him until the ambulance came."

"And how long was that?"

"I'd say about ten minutes."

Pearson nodded slowly. It was more than enough time; five minutes would have been sufficient. He said, "I'm afraid that that was the cause of death. The blood from the nosebleed ran back into the boy's throat. He was unable to breathe and he aspirated blood into the lungs. He died of asphyxiation."

The father's face revealed horror, incredulity. He said, "You mean . . . if we'd only turned him over . . ."

Pearson raised his hands expressively. "I meant what I said - I wish there were some other way to tell you this. But I can only report the truth: the original injuries to your boy were minor."

The patrolman said, "Then the blow from the car . . . ?"

"One can't be sure, of course, but my own opinion is that it was glancing and comparatively light." Pearson gestured to the mousy man, now standing close beside them. "I imagine this man is telling the truth when he says the car was moving slowly."

"Mother of God!" It came from the father - a despairing, tortured wail. He was sobbing, his hands to his face. After a moment the mousy man led him to a settee, his arm around the other's shoulders, his own eyes glistening.

The patrolman's face was white. He said, "Doctor, I was there all the time. I could have moved the boy . . . but I didn't know."

"I don't think you should blame yourself."

The man appeared not to have heard. He went on as if in a daze. "I took a first-aid course. I got a badge for it. All the time they taught us - don't move anybody; whatever you do, don't move them!"

"I know." Pearson touched the patrolman's arm gently. He said slowly, "Unfortunately there are some exceptions to the rule - one of them is when someone is bleeding in the mouth."

In the main-floor corridor on his way to lunch David Coleman saw Pearson emerge from the anteroom. At first Coleman wondered if the senior pathologist were ill. He seemed distracted, unaware of his surroundings. Then he caught sight of Coleman and moved toward him. The younger man halted.

"Oh yes . . . Dr. Coleman . . . There was something I had to tell you." Coleman sensed that for some reason Pearson was having trouble marshaling his thoughts. Now he reached out absently and grasped the lapel of Coleman's white lab coat. Coleman noticed that the old man's hands were nervous and fumbling. He disengaged his coat.

"What was it, Dr. Pearson?"

"There was . . . something to do with the lab." Pearson shook his head. "Well, it's gone now . . . I'll remember later." He seemed about to turn away when another thought came to him. "I think you'd better take over the autopsy room. Starting tomorrow. Keep your eye on things. See they do a good job."

"Very well. I'll be glad to do that." David Coleman had some clear-cut ideas about the performance of autopsies, and this would be an opportunity to put them into effect. It occurred to him that while they were talking he might as well bring up something else. He said, "I wonder if I could speak to you - about the laboratories."

"The laboratories?" The old man's mind still seemed to be elsewhere.

"You'll remember in my letter I suggested you might consider giving me charge of some part of the laboratories." It seemed a little odd to be discussing this here and now, but Coleman sensed the opportunity might not occur again.

"Yes . . . yes, I remember something being said." Pearson appeared to be watching a group of three moving down the corridor away from them - a policeman and a little man, supporting a bigger man in the middle.

"I wonder if I might start in Serology," Coleman said. "I'd like to do some checks on the procedures - standard lab checks, that is."

"Um? What was that?"

It was annoying to have to keep repeating things. "I said I would like to make some lab checks in Serology."

"Oh yes, yes . . . that's all right." Pearson said it absently. He was still looking away, down the corridor, when Coleman left.

Elizabeth Alexander was feeling good. About to begin lunch in Three Counties Hospital cafeteria, she realized she had been feeling that way for days, but especially so this morning. The child inside her was alive and stirring; even at this moment she could detect its movements faintly. She had just come from a department-store sale where, amid the melee of women, she had victoriously acquired some bright fabrics for the apartment, including one length for the tiny extra bedroom which was to be the baby's. And now she had met John.

It was the first time they had had a meal together in the hospital. Use of the cafeteria by employees' families was an unwritten privilege the hospital allowed, and John had learned about it a few days earlier. A few minutes ago they had lined up to select their food and Elizabeth had chosen a salad, soup, a roll, roast lamb with potatoes and cabbage, pie with cheese, and milk. John had asked good-humoredly, "Are you sure you have enough?"

Elizabeth selected a stick of celery. Biting into it, she said, "This is a hungry baby."

John smiled. A few minutes earlier, on the way to lunch, he had felt defeated and depressed, this morning's tongue-lashing by Dr. Pearson still fresh in mind. But Elizabeth's infectious spirits had caused him to shrug it off, at least for the time being. After all, he reflected, there would be no more trouble in the lab because from now on he intended to watch his step carefully. In any case, Dr. Pearson had now done the sensitization tests himself - in saline and high protein - and had pronounced both test results negative. "So far as your wife's blood is concerned," he had said, "there is nothing for anyone to worry about." In fact, he had been almost kindly about it - at least it seemed that way after the earlier outburst.

There was another thing to remember: Dr. Pearson was a pathologist and John was not. Maybe Dr. Pearson was right; perhaps John had placed too much importance on some of the things that were taught at technology school. Wasn't it a well-known fact that schools always pumped a lot of theory into you that you had no use for in the practical world outside? Goodness knows, he thought, there are plenty of subjects in high school and college that you never work at again once final exams are over. Couldn't this be the same thing? Couldn't John himself have taken too seriously the school theory about the need for a third sensitization test, whereas Dr. Pearson, with all his practical knowledge, knew it was unnecessary?

What was it Dr. Pearson had said while he was doing the tests this morning? "If we changed our laboratory methods every time something new came up, there'd never be any end to it. In medicine there are new ideas coming out every day. But in a hospital we have to make sure they're proven and valuable before we start to use them. Here we're dealing with people's lives and we can't afford to take chances."

John had not quite been able to see how an extra blood test would imperil anybody's life, but, all the same, Dr. Pearson did have a point about the new ideas. John knew from his own reading that there were lots of them around and not all good. Of course, Dr. Coleman had been pretty definite about the need for a third sensitization test. But then he was a lot younger than Dr. Pearson; certainly he had not had as much experience . . .

"Your soup's getting cold." Elizabeth broke in on his thoughts. "What are you so pensive about?"

"Nothing, honey." He decided to put the whole thing out of his mind. Elizabeth, at times, had a disconcerting habit of worming out his thoughts. "I meant to ask you last week," he said. "How was your weight?"

"It's about right," Elizabeth answered cheerfully. "But Dr. Dornberger said I have to eat well." She had finished her soup and was attacking the roast lamb hungrily.

Glancing up, John Alexander noticed Dr. Coleman approaching. The new pathologist was on his way to the tables where the medical staff usually sat. On impulse Alexander rose from his chair. "Dr. Coleman!"

David Coleman glanced across. "Yes?"

"Doctor, I'd like to have you meet my wife." Then, as Coleman came toward them, "Elizabeth, honey, this is Dr. Coleman."

"How do you do, Mrs. Alexander?" Coleman paused, holding the tray he had collected from the counter.

A trifle awkwardly John Alexander said, "You remember, honey? - I told you the doctor came from New Richmond too."

"Yes, of course," Elizabeth said. Then directly to Coleman, smiling, "Hullo, Dr. Coleman - I remember you very well. Didn't you used to come into my father's store sometimes?"

"That's right." He recalled her clearly now: a cheerful, long-legged girl who used to clamber obligingly around that cluttered, old-fashioned store, finding things that had got lost in the confusion. She didn't seem to have changed much. He said, "I think you once sold me some clothesline."

She answered brightly, "I believe I remember that. Was it all right?"

He appeared to ponder. "Now you mention it, I think it broke."

Elizabeth laughed. "If you take it back, I'm sure my mother will exchange it. She still runs the store. It's more of a mess than ever." Her good humor was infectious. Coleman smiled.

John Alexander had pulled back a chair. "Won't you join us, Doctor?"

For a moment Coleman hesitated. Then, realizing it would be churlish to refuse, "All right," he said. He put down his tray - it contained a Spartan lunch - a small fruit salad and a glass of milk - and sat at the table. Looking at Elizabeth, he said, "If I remember, didn't you have pigtails when I knew you?"

"Yes," she answered promptly, "and bands on my teeth as well. I grew out of them."

David Coleman found himself liking this girl. And seeing her here today had been like suddenly turning a page from the past. She reminded him of earlier years; Indiana had been a good place to live. He remembered the summers home from school, driving on rounds with his father in the doctor's old and battered Chevrolet. He said reflectively, "It's a long time since I was in New Richmond. My father died, you know, and Mother moved to the West Coast. There's nothing to take me back there now." Then drawing his thoughts away, "Tell me," he said to Elizabeth, "how do you like being married to a medical man?"

Swiftly John Alexander put in, "Not a medical man - just a technologist." When he had said it he wondered why. Perhaps it was a reflex action from what had happened this morning. A few minutes ago, when Coleman had joined them, John had considered telling him about the incident in the lab. But immediately afterward he had decided not to. Talking freely with Dr. Coleman had got him into enough trouble already. He decided to leave well enough alone.

"Don't sell technology short," Coleman said. "It's pretty important."

Elizabeth said, "He doesn't. But sometimes he wishes he had become a doctor instead."

Coleman turned to him. "Is that right?"

Alexander wished Elizabeth had not brought this up. He said reluctantly, "I did have ideas that way. For a time."

Coleman speared some fruit salad with his fork. "Why didn't you go to medical school?"

"The usual reasons - money mostly. I didn't have any, and I wanted to start earning."

Between mouthfuls Coleman said, "You could still do it. How old are you?"

Elizabeth answered for him. "John will be twenty-three. In two months' time."

"That's pretty old, of course." They laughed, then Coleman added, "You've still got time."

"Oh, I know." John Alexander said it slowly, thoughtfully, as if knowing in advance that his own argument was unconvincing. "The trouble is, it would mean a big financial struggle just when we're beginning to get settled. And besides, with a baby coming . . ." He left the sentence hanging.

Coleman took the glass of milk and drank deeply. Then he said, "Plenty of people have gone through medical school with a baby. And financial problems."

"That's exactly what I've been saying!" Elizabeth said it intensely, leaning forward across the table. "I'm so glad to hear it from someone else."

Coleman wiped his mouth with a napkin, then put it down. He looked directly at Alexander. He had a feeling that he had been right in his first impression of this young technologist. He seemed intelligent and conscientious; certainly he was interested in his work - that had been evident the other day. Coleman said, "You know what I think, John? I think if you feel like this, and don't go to medical school while you have the chance, it may be something you'll regret the rest of your life."

Alexander was looking down, absently moving his knife and fork.

Elizabeth asked, "There's still a need for a lot of doctors in pathology, isn't there?"

"Oh yes." Coleman nodded emphatically. "Perhaps more in pathology than anywhere else."

"Why is that?"

"There's a need of research for one thing - to keep medicine moving ahead; to fill in the gaps behind."

She asked, "What do you mean - the gaps behind?"

Momentarily the thought occurred to David Coleman that he was talking more freely than usual. He found himself about to express ideas which most of the time he kept locked in his own mind. But the company of these two had seemed refreshing, possibly because it was a change to be with someone younger after being around Dr. Pearson. Answering Elizabeth's question, he said, "In a way medicine is like a war. And, just as in a war, sometimes there's a spectacular advance. When that happens, people - doctors - rush to the new front. And they leave a lot of pockets of knowledge to be filled in behind."

Elizabeth said, "And that's the pathologist's job - to fill them?"

"It's the job of every branch of medicine. But sometimes in pathology there are more opportunities." Coleman thought a moment, then continued, "There's another thing too. All research in medicine is very much like building a wall. Someone adds a piece of knowledge - puts one brick on another; someone else adds one more, and gradually the wall grows. Finally someone comes along and puts the last brick on top." He smiled. "It isn't given to many to do spectacular things - to be a Fleming or a Salk. The best a pathologist can do, usually, is to make some modest contribution to medical knowledge - something within his own reach, within his own time. But at least he should do that."

John Alexander had been listening intently. Now he asked eagerly, "Will you be doing research here?"

"I hope so."

"On what?"

Coleman hesitated. This was something he had not spoken of before. But he had said so much now, he supposed one more thing would not make any difference. "Well, for one thing, on lipomas - benign tumors of fat tissue. We know very little about them." Unconsciously, as he had warmed to his subject, his normal coolness and reserve had fallen away. "Do you know there have been cases of men starving to death, yet having tumors thriving inside them? What I hope to do is - " He stopped abruptly. "Mrs. Alexander, is something wrong?"

Elizabeth had gasped suddenly and put her face in her hands. Now she took her hands away. She shook her head, as if to clear it.

"Elizabeth! What is it?" Alarmed, John Alexander jumped up from his chair. He moved to go around the table.

"It's . . . it's all right." Elizabeth motioned him back. She closed her eyes momentarily, then opened them. "It was just . . . for a moment - a pain, then dizziness. It's gone now."

She drank some water. Yes, it was true it had gone. But for a moment it had been like sharp hot needles - inside where the baby moved - then her head swimming, the cafeteria spinning around her.

"Has this happened before?" Coleman asked.

She shook her head. "No."

"Are you sure, honey?" It was John, his voice anxious.

Elizabeth reached across the table and put a hand on his. "Now don't begin worrying. It's too early for the baby. There's at least another four months to go."

"All the same," Coleman said seriously, "I suggest you call your obstetrician and tell him what happened. He might want to see you."

"I will." She gave him a warm smile. "I promise."

At the time Elizabeth had meant what she said. But afterward, away from the hospital, it seemed silly to bother Dr. Dornberger about a single pain that had come and gone so quickly. If it happened again, surely then would be the time to tell him - not now. She decided to wait.