A Case of Need

  “Not exactly. I overheard some of the residents say that you had a half-dozen pregnancy-positive scrapings in the last month. Have you been notified?”

  Immediately, the hearty manner was gone. “Yes,” he said, “I have.”

  “I just wanted you to know. There might be trouble in the tissue committee when these things come up, and—”

  He shook his head. “No trouble.”

  “Well, you know how it looks.”

  “Yes,” he said. “It looks like I’m performing abortions.”

  His voice was low, almost dead calm. He was looking directly at me. It gave me a strange feeling. “We’d better have a talk,” he said. “Are you free for a drink about six tonight?”

  “I guess so.”

  “Then meet me in the parking lot. And if you get some free time this afternoon, why don’t you have a look at a case of mine?”

  “All right,” I said, frowning.

  “The name is Suzanne Black. The number is AO—two-two-one-three-six-five.”

  I scribbled the number on a napkin, wondering why he should have remembered it. Doctors remember a lot about their patients, but rarely the hospital number.

  “Take a good look at this case,” Art said, “and don’t mention it to anyone until you talk to me.”

  Puzzled, I went back to work in the lab. I was up for an autopsy that day, so I wasn’t free until four in the afternoon. Then I went to the record room and pulled the chart for Suzanne Black. I read it right there—it wasn’t very long. She was Dr. Lee’s patient, first admitted at age twenty. She was a junior at a local Boston college. Her CC6 was menstrual irregularity. Upon questioning, it was revealed that she had recently suffered a bout of German measles, had been very tired afterward, and had been examined by her college doctor for possible mononucleosis. She reported irregular spotting approximately every seven to ten days, but no normal flow. This had been going on for the last two months. She was still tired and lethargic.

  Physical examination was essentially normal, except that she had a mild fever. Blood tests were normal, though hematocrit7 was somewhat low.

  Dr. Lee ordered a D & C to correct her irregularity. This was in 1956, before the advent of estrogen therapy. The D & C was normal; no evidence of tumors or pregnancy. The girl seemed to respond well to this treatment. She was followed for the next three months and had normal periods.

  It looked like a straightforward case. Illness or emotional stress can disrupt a woman’s biological clock, and throw off her menses; the D & C reset that clock. I couldn’t understand why Art had wanted me to look at it. I checked the path report on the tissue. It had been done by Dr. Sanderson. The write-up was brief and simple: gross appearance normal, micro examination normal.

  I returned the chart and went back to the lab. When I got there, I still couldn’t imagine what the point of the case was. I wandered around, doing odds and ends, and finally began the work-up on my autopsy.

  I don’t know what made me think of the slide. Like most hospitals, the Lincoln keeps path slides on file. We save them all; it is possible to go back twenty or thirty years and reexamine the microscopic slides from a patient. They’re stored in long boxes arranged like card catalogs in a library. We had a whole room full of such boxes.

  I went to the appropriate box and found slide 1365. The label gave the case number and Dr. Sanderson’s initials. It also said in large letters, “D & C.”

  I took the slide back to the micro room, where we have ten microscopes in a long row. One was free; I slipped the slide onto the stage and had a look.

  I saw it immediately.

  The tissue was a uterine scraping, all right. It showed a rather normal endometrium in the proliferative phase, but the stain stopped me. This slide had been stained with Zenker-Formalin stain, giving everything a brilliant blue or green color. It was a rather unusual stain, employed for special diagnostic problems.

  For routine work, the Hematoxylin-Eosin stain is used, producing pink and purple colors. Almost every tissue slice is stained with H & E, and if this is not the case, the reasons for the unusual stain are noted in the pathological summary.

  But Dr. Sanderson had not mentioned that the slide was Zenker-Formalin.

  The obvious conclusion was that the slides had been switched. I looked at the handwriting on the label. It was Sanderson’s, no doubt about it. What had happened?

  Almost immediately, other possibilities came to mind. Sanderson had forgotten to note in his report that an unusual stain was used. Or two sections were made, one H & E, the other Zenker-Formalin, and only the Zenker was saved. Or that there had been some legitimate mixup.

  None of these alternatives was particularly convincing. I thought about it and waited impatiently until six that evening, when I met Art in the parking lot and got into his car. He wanted to go someplace away from the hospital to talk. As he drove, he said, “Read the case?”

  “Yes,” I said. “Very interesting.”

  “You checked the section?”

  “Yes. Was it the original?”

  “You mean, was it a scraping from Suzanne Black? No.”

  “You should have been more careful. The stain was different. That kind of thing can get you into trouble. Where did the slide come from?”

  Art smiled thinly. “A biological supply house. ‘Slide of normal endometrial scraping.’ ”

  “And who made the switch?”

  “Sanderson. We were new to the game, in those days. It was his idea to put in a phony slide and write it up as normal. Now, of course, we’re much more refined. Every time Sanderson gets a normal scraping, he makes up a few extra slides and keeps them around.”

  “I don’t understand,” I said. “You mean Sanderson is in this with you?”

  “Yes,” Art said. “He has been for several years.” Sanderson was a very wise, very kind, and very proper man.

  “You see,” Art said, “that whole chart is a lie. The girl was twenty, all right. And she had German measles. And she had menstrual irregularity, too, but the reason was she was pregnant. She had been knocked up on a football weekend by a guy she said she loved and was going to marry, but she wanted to finish college first, and a baby would get in the way. Furthermore, she managed to get measles during the first trimester. She wasn’t a terribly bright girl, but she was bright enough to know what it meant when you got measles. She was very worried when she came to see me. She hemmed and hawed for a while, and then blurted it all out and asked for an abortion.

  “I was pretty horrified. I was fresh from my residency, and I still had a little starry idealism in me. She was in a terrible fix; she was a wreck and acted as if the world had collapsed around her. I guess in a way it had. All she could see was her problem as a college dropout, the unwed mother of a possibly deformed child. She was a nice enough girl, and I felt sorry for her, but I said no. I sympathized with her, feeling rotten inside, but I explained that my hands were tied.

  “So then she asked me if it was a dangerous operation, to have an abortion. At first I thought she was planning to try it on herself, so I said it was. Then she said she knew of a man in the North End who would do it for two hundred dollars. He had been a medical orderly in the Marines, or something. And she said that if I wouldn’t do it for her, she’d go to this man. And she walked out of my office.”

  He sighed and shook his head as he drove.

  “I went home that night feeling like hell. I hated her: I hated her for intruding on my new practice, for intruding on my neatly planned life. I hated her for the pressure she was putting on me. I couldn’t sleep; I kept thinking all night. I had a vision of her going to a smelly back room somewhere and meeting a leering little guy who would letch her and maybe even manage to kill her. I thought about my own wife and our year-old baby, and how happy it could all be. I thought about the amateur abortions I’d seen as an intern, when the girls came in bleeding and foaming at three in the morning. And let’s face it, I thought about the sweats I’d had in college
. Once with Betty, we sat around for six weeks waiting for her period. I knew perfectly well that anybody can get pregnant by accident. It’s not hard, and it shouldn’t be a crime.”

  I smoked a cigarette and said nothing. “So I got up in the middle of the night and fought it out with six cups of coffee, staring at the kitchen wall. By morning I had decided that the law was unfair. I had decided that a doctor could play God in a lot of crappy ways, but this was a good way. I had seen a patient in trouble and I had refused to help her when it was within my power. That was what bothered me—I had denied her treatment. It was just as bad as denying penicillin to a sick man, just as cruel and just as foolish. The next morning, I went to see Sanderson. I knew he had liberal ideas about a lot of things. I explained the whole situation and told him I wanted to do a D & C. He said he would arrange to do the path examination himself, and he did. That was how it all started.”

  “And you’ve been doing abortions ever since?”

  “Yes,” Art said. “When I’ve felt that they were warranted.”

  After that, we went to a bar in the North End, a simple place, filled with Italian and German laborers. Art was in a talkative, almost confessional mood.

  “I often wonder,” he said, “about what medicine would be like if the predominant religious feeling in this country were Christian Scientist. For most of history, of course, it wouldn’t have mattered; medicine was pretty primitive and ineffective. But supposing Christian Science was strong in the age of penicillin and antibiotics. Suppose there were pressure groups militating against the administration of these drugs. Suppose there were sick people in such a society who knew perfectly well that they didn’t have to die from their illness, that a simple drug existed which would cure them. Wouldn’t there be a roaring black market in these drugs? Wouldn’t people die from home administration of overdoses, from impure, smuggled drugs? Wouldn’t everything be an unholy mess?”

  “I see your analogy,” I said, “but I don’t buy it.”

  “Listen,” he said. “Morality must keep up with technology, because if a person is faced with the choice of being moral and dead or immoral and alive, they’ll choose life every time. People today know that abortions are safe and easy. They know it isn’t a long, tedious, dangerous operation. They know it’s simple and they want the personal happiness it can give them. They demand it. And one way or another they get it. If they’re rich, they go to Japan or Puerto Rico; if they’re poor, they go to the Marine orderly. But one way or another, they get that abortion.”

  “Art,” I said. “It’s illegal.”

  He smiled. “I never thought you had so much respect for the law.”

  That was a reference to my career. After college, I entered law school and stuck it out for a year and a half. Then I decided I hated it and quit to try medicine. In between, I did some army time.

  “But this is different,” I said. “If they catch you, they’ll toss you in the clink and take away your license. You know that.”

  “I’m doing what I have to do.”

  “Don’t be an ass.”

  “I believe,” he said, “that what I’m doing is right.” Looking at his face, I saw he meant it. And as time went on, I personally encountered several cases where an abortion was the obvious, humane answer. Art handled them. I joined Dr. Sanderson in covering up in the path department. We fixed things so that the tissue committee never knew. That was necessary because the tissue committee of the Lincoln was composed of all the chiefs of service, as well as a rotating group of six doctors. The average age of the men on the tissue committee was sixty-one, and, at any given time, at least a third were Catholic.

  Of course it was not a well-kept secret. Many of the younger doctors knew what Art was doing, and most agreed with him, because he exercised careful judgment in deciding his cases. Most would have performed abortions too, if they had dared.

  A few didn’t agree with Art and would have been tempted to turn him in if they’d had the guts. Anal retentives like Whipple and Gluck, men whose religion precluded compassion and common sense.

  For a long time, I worried about the Whipples and the Glucks. Later on I ignored them, turning away from their nasty knowing glances and pinched, disapproving faces. Perhaps that was a mistake.

  Because now Art was down, and if his head rolled, so would Sanderson’s. And so would mine.

  THERE WAS NO PLACE TO PARK near the police station. Finally I came to a lot four blocks away and walked quickly back to find out why Arthur Lee was in jail.

  Geriatrics.

  The files containing the history of treatment of patients in the hospital. Called a “chart” because the bulk of the file consists of daily charts of temperature, blood pressure, pulse and respiration, the so-called “vital signs.”

  Diagnosis.

  Crepitant means it is crackly and filled with air. This is normal.

  Emergency ward.

  Chief complaint, the term for the medical disorder that brings the patient to seek treatment.

  A test of the amount of hemoglobin, or red cells, in the blood.

  TWO

  WHEN I WAS IN THE ARMY a few years back, I served as an MP in Tokyo, and the experience taught me a lot. MP’s were the most unpopular people in the city in those days, during the last phases of the occupation. In our white helmets and uniforms, we represented the final reminders of a tiresome military authority to the Japanese. To the Americans on the Ginza, drunk with sake or whiskey if they could afford it, we represented all that was frustrating or constricting about rigid military life. We were therefore a challenge to anyone who saw us, and more than one of my friends ran into trouble. One was blinded by a knife in the eye. Another was killed. Of course, we were armed. I remember when we were first issued our guns, a hard-nosed captain said to us: “You have your weapons, now take my advice: never use the gun. You shoot a rowdy drunk, even in self-defense, and you’ll find out later his uncle is a congressman or a general. Keep the gun in sight, but keep it in your holster. Period.”

  In effect we were ordered to bluff our way through everything. We learned to do it. All cops learn to do it.

  I remembered this as I faced the surly police sergeant in the Charles Street Station. He looked up at me as if he’d enjoy breaking my skull.

  “Yeah? What is it?”

  “I’m here to see Dr. Lee,” I said.

  He smiled. “The little chink’s uptight, is he? Too bad.”

  “I’m here to see him,” I repeated.

  “Can’t.”

  He looked back at his desk and shuffled the papers on it in a busy, irritable dismissal. “Would you care to explain that?”

  “No,” he said. “I wouldn’t care to explain that.”

  I took out my pen and notebook. “I’d like your badge number, please.”

  “What are you, a funny guy? Beat it. You can’t see him.”

  “You are required by law to give your badge number upon request.”

  “That’s nice.”

  I looked at his shirt and pretended to write down the number. Then I started for the door.

  He said casually, “Going somewhere?”

  “There’s a phone booth right outside.”

  “So?”

  “It’s a shame. I’ll bet your wife spent hours sewing those stripes on your shoulder. It takes them ten seconds to get them off. They use a razor blade: doesn’t even damage the uniform.”

  He stood up heavily behind the desk. “What’s your business here?”

  “I’ve come to see Dr. Lee.”

  He looked at me evenly. He didn’t know if I could have him busted, but he knew it could be done.

  “You his lawyer?”

  “That’s right.”

  “Well, for Christ’s sake, you should have said so before.” He took a set of keys from his desk drawer. “Come on.” He smiled at me, but his eyes were still hostile.

  I followed him back through the station. He said nothing, but grunted a couple of times. Finally he
said over his shoulder, “You can’t blame me for being careful. Murder is murder, you know.”

  “Yes,” I said.

  ART WAS LOCKED IN A NICE CELL. It was tidy and didn’t smell much. Actually, Boston has some of the nicest cells in America. They have to: lots of famous people have spent time in those cells. Mayors, public officials, people like that. You can’t expect a man to run a decent campaign for reelection if he’s in a lousy cell, can you? It just wouldn’t look right.

  Art was sitting on his bed, staring at a cigarette between his fingers. The stone floor was littered with butts and ash. He looked up as we came down the hallway.

  “John!”

  “You have him for ten minutes,” the sergeant said.

  I entered the cell. The sergeant locked the door behind me and stood there, leaning against the bars.

  “Thank you,” I said. “You can go now.” He gave me a mean look and sauntered off, rattling the keys.

  When we were alone, I said to Art, “You all right?”

  “I think so.”

  Art is a small, precise man, a fastidious dresser. Originally he’s from San Francisco from a large family of doctors and lawyers. Apparently his mother was American: he doesn’t look very Chinese. His skin is more olive than yellow, his eyes lack epicanthic folds, and his hair is light brown. He is very nervous, constantly moving his hands in fluttering movements, and the total effect is more Latin than anything else.

  He was pale now and tense. When he got up to pace the cell, his movements were quick and abrupt.

  “It was good of you to come.”

  “In case there’s any question, I’m the representative of your lawyer. That’s how I got in here.” I took out my notebook. “Have you called your lawyer?”

  “No, not yet.”

  “Why not?”

  “I don’t know.” He rubbed his forehead and massaged his eyes with his fingers. “I’m not thinking straight. Nothing seems to make sense….”