The Final Diagnosis

A police patrolman on duty at Main and Liberty heard the ambulance's siren six blocks away. Moving out from the sidewalk, and with the skill of long practice, he began to expedite the traffic flow so as to leave the intersection clear. As the siren grew louder and the flashing warning light became visible, threading its way toward him, the patrolman inflated his cheeks and blew two sharp whistle blasts. Then, signaling a halt to all traffic in the side roads, he authoritatively waved the ambulance driver through a red light. Pedestrians at the intersection, turning their heads curiously, caught a blurred glimpse of a young woman's white face as the ambulance swept by.

Inside, Elizabeth was only dimly conscious of their progress through the busy city streets. She sensed they were moving fast, but the buildings and people outside were a confused pattern racing past the window near her head. Momentarily, between each onset of pain, she could see the driver up ahead, his two big hands nursing the wheel, turning quickly, first right, then left, taking advantage of every opening as it occurred. Then the pain came back and all she could think of was to cry out and to hold on.

"Hold my wrists! And hang on all you want." It was the ambulance attendant, leaning over her. He had a stubble of beard and a cleft chin, and for a moment Elizabeth believed it was her father come here now to comfort her. But her father was dead; hadn't he been killed at the railroad? Or perhaps he had not and he was in this ambulance along with her, being taken to some place they could be cared for together. Then her head cleared and she saw it was not her father but a stranger whose wrists were red with the gouge marks her nails had made.

She had time to touch the marks before the next pain came. It was a gesture, all she could do. The man shook his head. "Don't worry. Just you hold on all you want. We'll be there soon. Old Joe up front is the best wagon driver in the city." Then the pain again, worse than before, the intervals between growing shorter, the sensation as if all her bones were being twisted beyond endurance with the agony centered in her back, the torture of it overflowing into a flame of red, yellow, purple in front of her eyes. Her nails dug deeper and she screamed.

"Can you feel the baby coming?" It was the attendant again; he had waited until the last pain subsided, then leaned close.

She managed to nod her head and gasp. "I . . . I think so."

"All right." He eased his hands gently away. "Hang on to this for a minute." He gave her a towel he had rolled tight, then turned back the blanket over the stretcher and began to loosen her clothing. He talked softly while he worked. "We'll do the best we can if we have to. It wouldn't be the first one I've delivered in here. I'm a grandfather, you see, so I know what it's all about." His last words were drowned out by her cry; once more, at her back, flooding around her, blinding, overpowering, the crescendo of agony, crushing, unrelenting. "Please!" She grasped for his wrists again, and he gave them, faint lines of blood appearing as her nails ripped flesh. Turning his head, he called forward, "How are we doing, Joe?"

"Just went through Main and Liberty." The big hands turned the wheel sharply right. "There was a cop there; he had it sorted. Saved us a good minute." A swing to the left, then the head leaned back. "You a godfather yet?"

"Not quite, Joe. It's getting pretty close though, I reckon."

Again the wheel spinning; a sharp turn to the right. Afterward: "We're on the home stretch, boy. Try to keep the cork in a minute more."

All Elizabeth could think, through the miasma that engulfed her, was: My baby - he'll be born too soon! He'll die! Oh God, don't let him die! Not this time! Not again!

In Obstetrics, Dr. Dornberger was scrubbed and gowned. Emerging from the scrub room into the busy interior hallway which separated the labor rooms from the delivery areas, he looked around him. Seeing him through the glass partitions of her office, Mrs. Yeo, the head nurse, got up and came toward him, holding a clip board.

"Here's the blood-sensitivity report on your patient, Dr. Dornberger. It just came in from Pathology." She held out the board so he could read without touching it.

"About time!" Unusual for him, it was almost a growl. Scanning the form on top of the clip board, he said, "Sensitivity negative, eh? Well, there's no problem there. Is everything else ready?"

"Yes, Doctor." Mrs. Yeo smiled. She was a tolerant woman who felt that every man, including her own husband, was entitled to be grouchy now and then.

"How about an incubator?"

"It's here now."

As Dornberger glanced around, a nurse held the outer doorway wide while a woman orderly wheeled in an Isolette incubator. Holding the trailing cord clear of the floor, the orderly glanced inquiringly at Mrs. Yeo.

"In number two, please."

The orderly nodded and wheeled the incubator through a second swing door immediately ahead. As it closed behind her a girl clerk came toward them from the nursing office.

"Excuse me, Mrs. Yeo."

"Yes?"

"Emergency just phoned." The girl turned to Dornberger. "Your patient just arrived, Doctor, and she's on the way up. They say she's well advanced in labor."

Ahead of the hospital stretcher, to which she had been transferred from the ambulance, Elizabeth could see the young intern who had received her on arrival. Moving forward at a steady but unhurried pace, he was clearing a way, calmly and methodically, through the groups of people in the busy main-floor corridor. "Emergency . . . emergency, please." The words were quiet, almost casual, but their effect was immediate. Passers-by halted, groups moved back against the wall, to allow the small procession - intern, stretcher, and nurse propelling it - to go by. At the corridor's end an elevator operator had seen them and was clearing the car.

"Next car, please. This car for an emergency." Obediently the occupants moved out and the stretcher rolled in. The smooth, established drill of hospital procedure was functioning effortlessly to admit another supplicant.

Something of the calm seemed to transfer itself to Elizabeth. Though the pain was continuous now, and a new pressure in her uterus was building up, she found herself able to endure both better than before. She discovered that by biting her lower lip, and by gripping the edge of the sheet which covered her, it was possible not to cry out. She knew, though, that the final stage of birth had begun; involuntarily she began to bear down and, between her thighs, felt the first beginning of emergence.

Now they were in the elevator with the doors gliding closed and the nurse behind reaching down and holding her hand. "Just a minute or two more; that's all it will be." Then the doors were opened again and she saw Dr. Dornberger, gowned and waiting for her.

As if there were a hope that he had misread them earlier, Dr. Pearson picked up the two telegrams again. Looking at them, he put them down one at a time. "Malignant! Benign! And no doubt in either one. We're back where we started."

"Not quite," David Coleman said quietly. "We've lost almost three days."

"I know! I know!" Joe Pearson was beating a bulky fist into his palm, uncertainty around him like a mantle. "If it is malignant, the leg has to be amputated quickly; otherwise we'll be too late." He turned to face Coleman directly. "But the girl's nineteen. If she were fifty I'd say malignant and never turn a hair. But nineteen! - and maybe have your leg off when you didn't need to."

Despite his feelings about Pearson, despite his own conviction that the tissue they were speaking of was benign and not malignant, Coleman felt his sympathy for Pearson grow. The old man did have the final responsibility in the case; it was understandable that he should be troubled; the decision was extremely tough. He said tentatively, "It takes a lot of courage to make this kind of diagnosis."

As if he had touched a match to open flame, Pearson flared up. "Don't give me any of your high-school cliches! I've been doing this for thirty years!" He glared at Coleman, eyes blazing, the earlier antagonism returning. At that moment the telephone rang.

"Yes?" Though Pearson had answered the phone brusquely, as he listened his expression softened. Then he said, "All right, Lucy. I think you'd better come down. I'll wait for you here." Replacing the phone, he stood looking down at a point in the center of his desk. Then, without raising his head, he said to Coleman, "Lucy Grainger's on her way. You can stay if you want."

Almost as if he had not heard, Coleman said thoughtfully, "You know, there's one other thing might work, might give us a better pointer."

"What?" Pearson raised his head abruptly.

"That X-ray that was done." Coleman was still going slowly, the words keeping pace with his thoughts. "It was taken two weeks ago. If there is a tumor, and it's developing, another X-ray might show it."

Without a word Pearson reached down and once more picked up the telephone. There was a click and then he said, "Get me Dr. Bell in Radiology." Waiting, the old man eyed Coleman strangely. Then, covering the mouthpiece, he said with grudging admiration, "I'll say this for you: you're thinking - all the time."

In the room which the hospital staff jestingly referred to as "the expectant father's sweatbox" John Alexander butted a half-smoked cigarette into an ash stand. Then he got up from the padded leather chair where he had sat for the last hour and a half, looking up each time the door opened and someone had come in from the corridor outside. On each occasion, though, the news had been for someone else, and now, of the five men who had occupied the room ninety minutes ago, only he and one other remained.

Crossing to the big windows which looked down on the hospital forecourt and across other buildings to the industrial heart of Burlington, he saw that the streets and roofs were wet. It must have rained since he had come here without his noticing it. Now the area surrounding the hospital looked its worst - squalid and depressing, the roofs of mean houses and tenements stretching away toward the factories and grimy smokestacks lining both banks of the river. Glancing down at the street on which the hospital fronted, he saw a group of children run from an alley, nimbly dodging the pools of water left by the rain or broken sidewalks. Watching them, he saw one of the bigger boys in the group halt and put out a foot to trip a child behind. It was a small girl, probably four or five, and she fell face forward into one of the larger puddles, dirty water splashing up around her. She arose crying, wiping streaks of mud from her face and attempting pathetically to wring the water from her soiled, soaked dress. By now the others had stopped and they formed a ring around her, dancing and, from their expressions, chanting derision.

"Kids!" The disgusted voice came from alongside, and John was aware for the first time that the other occupant of the room had joined him at the window. Glancing sideways, he saw that the man was tall and pencil thin; hollow cheeks made him appear gaunt, and he was in need of a shave. Probably twenty years older than John, he wore a stained corduroy jacket with soiled coveralls beneath. With him across the room he brought an odor of grease and stale beer.

"Kids! They're all alike!" The man turned away from the window and began fumbling in his pockets. After a moment he produced paper and tobacco and began to roll a cigarette. Looking sharply at John, he asked, "This your first?"

"Not really. It's our second, but the first baby died."

"We lost one like that - in between the fourth and the fifth. A good thing too." The other man was searching his pockets. He asked, "You got a light?"

John produced a lighter and held it out. He asked, "You mean this is your sixth?"

"No - eighth." The thin man had his cigarette going now. "Sometimes I reckon that's eight too many." Then he said sharply, "I suppose you wanted yours."

"The baby, you mean?"

"Yeah."

"Yes, of course." John sounded surprised.

"We never did. Not after the first - that was more than enough for me."

"Why did you have eight then?" John felt impelled to ask; the conversation had taken on an almost hypnotic quality.

"My wife could tell you better'n me - she's the one with the hot pants. Give her a couple of beers, let her wiggle her behind at a dance, and she's got to have it right there and then, and no messing around waiting to get home." The thin man blew out smoke, then went on calmly, "I reckon all our kids have been started in queer places. Once we was shopping in Macy's and we had it in a broom closet in the basement. That's where our fourth came from, I reckon - Macy's basement, but no bargain."

For a moment John was ready to laugh aloud, then he remembered his own reason for being there and stopped. Instead he said, "I hope everything's all right for you - this time, I mean."

The gaunt man said gloomily, "It's always all right; that's our trouble." He returned to the other side of the room and picked up a newspaper.

Left alone, John glanced at his watch again. He saw that it was an hour and three quarters since he had come here; surely there must be something soon in the way of news. He wished he had seen Elizabeth before she had gone into the delivery room, but everything had happened so quickly that there had not been time. He had been in the hospital kitchens when Carl Bannister had come to bring him the news. John had gone to the kitchens on Dr. Pearson's instructions. Pearson had told him to take cultures from plates which had passed through the kitchen dishwashers; John gathered that the machines were suspected of being unhygienic. But he had left the work as soon as Bannister had told him about Elizabeth and had gone to Emergency, hoping to intercept her there. But by that time she had already arrived by ambulance and had gone upstairs to Obstetrics. It was after that that he had come straight here to wait.

Now the door from the corridor opened, and this time it was Dr. Dornberger. From his face John tried to read the news, but without success. He asked, "You are John Alexander?"

"Yes, sir." Though, he had seen the elderly obstetrician several times in the hospital, this was the first time they had spoken to each other.

"Your wife is going to be all right." Dornberger knew better than to waste time on preliminaries.

John's first impression was of overwhelming relief. Then he asked, "The baby?"

Dornberger said quietly, "You have a boy. He was premature, of course, and I have to tell you, John - he's very frail."

"Will he live?" Only when he had asked the question did it occur to him how much depended on the answer.

Dornberger had taken out his pipe and was filling it. He said evenly, "Let's say the chances are not as good as if he had gone to full term."

John nodded dully. There seemed nothing to say, nothing that would matter now.

The older man paused to put away his tobacco pouch. Then in the same quiet, careful tone he said, "As near as I can tell, you have a thirty-two-week baby; that means he was born eight weeks early." Compassionately he added, "He wasn't ready for the world, John; none of us are that soon."

"No, I suppose not." John was scarcely conscious of speaking. His mind was on Elizabeth and what this baby was to have meant to them both.

Dr. Dornberger had produced matches and was lighting his pipe. When he had it going he said, "Your baby's birth weight was three pounds eight ounces. Perhaps that will mean more if I tell you that nowadays we consider any baby less than five pounds eight ounces at birth to be premature."

"I see."

"We have the baby in an incubator, of course. Naturally we'll do everything we can."

John looked at the obstetrician directly. "Then there is hope."

"There's always hope, son," Dornberger said quietly. "When we haven't much else, I guess there's always hope."

There was a pause, then John asked, "May I see my wife now?"

"Yes," Dornberger said. "I'll come to the nursing station with you."

As they went out John saw the tall, gaunt man watching him curiously.

Vivian was not quite sure what was happening. All she knew was that one of the staff nurses had come into her room and told her they were going to Radiology immediately. With help from another student nurse she had been put on a stretcher and now was being wheeled along the corridors where so short a time ago she had walked herself. Her movement through the hospital had a dream-like quality; it complemented the unrealness of everything else that had happened so far. Momentarily Vivian found herself abandoning fear, as if whatever followed could not matter to her in the end because it was inevitable and would not be changed. She found herself wondering if this feeling were a form of depression, of abandoning hope. She had known already that this was the day which might bring the verdict she had dreaded, a verdict which would make her a cripple, depriving her of freedom of movement, removing from her in one swift stroke so many things she had taken for granted until this time. With this latest thought the moment of passivity left her and fear came crowding back. She wished desperately that Mike were with her at this moment.

Lucy Grainger met the stretcher at the entrance to Radiology. "We've decided to do another X-ray, Vivian," she said. "It won't take long." She turned to a white-coated man beside her. "This is Dr. Bell."

"Hullo, Vivian." He smiled at her through thick horn-rimmed glasses, then, to the nurse, "May I have the chart, please?" As he studied it, turning the pages quickly, Vivian moved her head to look around her. They were in a small reception room with a glass-enclosed nursing station in one corner. Against one wall other patients were seated - two men in wheel chairs wearing pajamas and hospital robes, and a woman and a man in street clothes, the latter with a cast around his wrist. The last two, she knew, would have come here either from Outpatients or Emergency. The man with the cast looked uncomfortable and out of place. In his good hand was clasped a printed form; he seemed to be clutching it as if it were a passport he would need to come and go from these alien surroundings.

Bell finished reading the chart and handed it back. He said to Lucy, "Joe Pearson phoned me. I gather that you'd like to re-X-ray, so we can see if there's any change in the bone appearance."

"Yes." Lucy nodded. "It's Joe's idea that something" - she hesitated, aware that Vivian would hear her words - "might have become visible in the meantime."

"It's possible." Bell had crossed to the nursing station and was scribbling an X-ray requisition. He asked a girl clerk behind the desk, "Which technicians are free?"

She consulted a list. "There's Jane or Mr. Firban."

"I think we'll have Firban do this one. Will you find him, please?" He turned to Lucy as they moved back toward the stretcher. "Firban's one of our best technicians, and we want good films." He smiled at Vivian. "Dr. Pearson-asked me to take a personal interest in this case, so that's what I'm doing. Now let's go in this room over here."

With help from Bell the nurse guided the stretcher out of the reception area and into a larger room opening from it. Most of the room was taken up by an X-ray table, with the machine's picture tube above and suspended on overhead rollers. In an adjoining smaller section, behind thick glass, Vivian could see an electric control panel. Almost at once they were followed into the room by a short, youngish man with crew-cut hair and wearing a white lab coat. His movements were jerky and hurried, as though he wished to achieve whatever he was doing quickly but with a minimum of energy expended. He glanced at Vivian, then turned to Bell.

"Yes, Dr. Bell?"

"Oh, Karl, I'd like you to handle this case for me. By the way, do you know Dr. Grainger?" To Lucy, "This is Karl Firban."

"I don't think we've met." Lucy offered her hand and the technician took it.

"How do you do, Doctor."

"And our patient is Vivian Loburton." Bell smiled down at the stretcher. "She's a student nurse. That's why we're making such a fuss over her."

"Hullo, Vivian." Firban's greeting was as taut as his other actions. Now, swinging the X-ray table from a vertical position to horizontal, he talked on with brisk brightness. "For special customers we offer a choice of Vista Vision or CinemaScope - all in glorious gray and black." He glanced at the requisition which Bell had put down. "The left knee, eh? Anything special, Doctor?"

"We'll want some good A.P., lateral and oblique views, and then I think a coned-down view of the knee area." Bell paused and considered. "I'd say about five or six films, and then duplicates of the opposite extremity."

"Do you want any views on a fourteen by seventeen, to include the anterior tibia and fibula?"

Bell considered, then nodded. "That might be a good idea." To Lucy he said, "If it's osteomyelitis there could be periosteal reaction further down the bone."

"All right, Doctor. I'll have something for you in half an hour." It was a polite hint from Firban that he preferred to work alone, and the radiologist accepted it.

"We'll have a coffee and come back." Bell smiled in Vivian's direction. "You're in good hands." Then, with Lucy ahead of him, he went outside.

"All righty. Let's get to work." The technician motioned to the nurse, and together they eased Vivian from the stretcher to the X-ray table. After the stretcher's comparative softness the black ebonite table felt hard and unyielding.

"Not so comfortable, eh?" Firban was moving Vivian carefully into the position he wanted, leaving her left knee exposed. As she shook her head he went on, "You get used to it. I've slept on this table plenty of times when I've been on night duty and things have been quiet." He nodded to the nurse, and the girl went to wait behind the glassed-in section.

With Vivian watching, the technician went through the routine movements of an X-ray series. Still with the same swift jerkiness, he took a film casette from an upright container built into the wall, inserting it deftly in a tray beneath the X-ray table. Next he positioned the tray below the area of Vivian's knee. Then, using press-button controls suspended from the ceiling by a heavy electrical cord, he maneuvered the heavy X-ray tube along its rollers and downward, until it was immediately above the knee, the arrow on the machine's calibrated height scale pointing to forty inches.

In contrast to so much else in the hospital, Vivian thought, this room appeared almost unearthlike and remote. The shining black and chrome machinery seemed monstrous as it slid slowly and in massive murmur. There was an aura of science and neutrality in this place, in a way as remote from medicine as a great ship's engine room might seem from a sunlit bridge deck far above. And yet here, with these ominous, ponderous instruments, so much of medicine's real detective work was done. The thought for a moment frightened her. There was a dreadful impersonality in it all, so little of people in these machines. Whatever they might discover was relayed and reported without warmth or pleasure, without sadness or regret. Good, bad - it was all the same. For a moment she fancied the picture tube suspended above her to be an eye of judgment, inflexible, dispassionate. What was its judgment now? Would there be hope, or even reprieve . . . or a solemn sentence from which there could be no appeal? Again she found herself wishing for Mike; she would call him as soon as she returned to the hospital room.

The technician had finished his preparation. "I think that will do." He took a final look around. "I'll tell you when to keep perfectly still. This is the only place in the hospital, you know, where we can say you won't feel a thing and really mean it."

Now he moved behind the inch-thick glass screen which protected the X-ray operator from radiation. Out of the periphery of her vision Vivian could see him moving, holding a check list, setting switches.

At the master control panel Firban was thinking: A pretty kid. Wonder what's wrong. Must be something serious for Bell to take all that interest; usually the chief doesn't pay attention to patients until after the films are made. He double-checked the panel controls; in this work you acquired the habit of taking no chances. Settings were okay - 84 kilovolts, 200 milliamps, exposure time fifteen hundredths of a second. He pressed a button which set the rotating anode of the picture tube in motion. Then calling out the familiar formula, "Don't move! Keep still!" he thumbed the second button and knew that whatever was to be seen by the osmotic eye of X-ray was recorded now for others to evaluate.

In the X-O-Mat room of Radiology, the Venetian blinds lowered to cut off the light from outside, Drs. Bell and Lucy Grainger were waiting. In a few minutes the films which Firban had taken would be ready for comparison with those of two weeks before. The technician had already fed his undeveloped negatives into the autodeveloping machine, and at this moment, looking somewhat like an oversized oil furnace, its interior was humming. Now, one by one, the developed films began to fall too a slot at the front of the machine.

As each film appeared Bell placed it under the clip of a viewing box, lighted by fluorescent tubes behind. On a second viewing box, immediately above, he had already put in position the earlier films.

"Did we get good pictures?" There was a touch of pride in the technician's question.

"Very good indeed." It was a reflex answer; Bell was already studying the new negatives intently, then comparing the corresponding areas in the two sets of films. He used a pencil point to aid his own thought process and so that Lucy could follow him.

When they had gone over both sets completely, Lucy asked, "Do you see any difference? I can't, I'm afraid."

The radiologist shook his head. "There's a little periosteal reaction here." He pointed with the pencil to a slight difference in gray shading at two points. "But that's probably the result of your own biopsy. Otherwise there's been no conclusive change." Bell removed his heavy glasses and rubbed his right eye. He said, almost apologetically, "I'm sorry, Lucy; I guess I have to throw the ball back at Pathology. Will you tell Joe Pearson, or shall I?" He began to take down the two sets of films.

"I'll tell him," Lucy said thoughtfully. "I'll go and tell Joe now."