A Case of Need

  The frequently bizarre cases mean that every doctor and surgeon has a backlog of strange stories. One surgeon is fond of telling how he was on the Accident Floor—the City’s EW—when two victims of an auto accident were brought in. One man had lost his leg at the knee. The other had massive crush injury to the chest, so bad that the degree of damage could not at first be ascertained from the heavy bleeding. On an X ray of the chest, however, it was seen that one man’s foot and lower leg had been rammed into the second man’s chest, where it was lodged at the time of admission.

  Dead on arrival at hospital.

  The seeping of blood to the lowest portions of the body after death. It often helps establish the position of the body.

  Pelvic Inflammatory Disease, usually infection of the fallopian tubes by Neisseria gonococcus, the agent of gonorrhea. Gonorrhea is considered to be the most common infectious disease of mankind. Twenty percent of prostitutes are thought to be infected.

  Deaner is a traditional term for the man who takes care of the dissecting room. It is an ancient term, dating back to the days when anatomy dissections were done by horse gelders and butchers. The deaner keeps the rooms clean, cares for the corpses, and aids in the dissection.

  A drug to contract the uterus, useful for initiating birth and for stopping uterine bleeding.

  See Appendix I: Delicatessen Pathologists.

  SIX

  I HAVE TROUBLE BUYING LIFE INSURANCE. Most pathologists do: the companies take one look at you and shudder—constant exposure to tuberculosis, malignancies, and lethal infectious disease makes you a very poor risk. The only person I know who has more trouble getting insured is a biochemist named Jim Murphy.

  When he was younger, Murphy played halfback for Yale and was named to the All-East team. That in itself is an accomplishment, but it is amazing if you know Murphy and have seen his eyes. Murphy is practically blind. He wears lenses an inch thick and walks with his head drooping, as if the weight of the glass burdened him down. His vision is barely adequate under most circumstances, but when he gets excited or tight, he walks into things.

  On the surface it would not seem that Murphy had the makings of a halfback, even at Yale. To know his secret, you have to see him move. Murphy is fast. He also has the best balance of anyone I know. When he was playing football, his teammates devised a series of plays especially designed to allow the quarterback to point Murphy in the proper direction and send him on his way. This usually worked, though on several occasions Murphy made brilliant runs in the wrong direction, twice charging over the goal line for a safety.

  He has always been drawn to unlikely sports. At the age of thirty, he decided to take up mountain climbing. He found it very agreeable, but he couldn’t get insured. So he switched to sports-car racing and was doing very well until he drove a Lotus off the track, rolled it four times, and broke both clavicles in several places. After that, he decided he’d rather be insured than active, so he gave it all up.

  Murphy is so fast he even speaks in a kind of shorthand, as if he can’t be bothered putting all the articles and pronouns into his sentences. He drives his secretaries and technicians mad, not only because of his speech, but also because of the windows. Murphy keeps them wide open, even in winter, and he is an unrelenting opponent of what he calls “bad air.”

  When I walked into his lab in one wing of the BLI1 I found it filled with apples. There were apples in the refrigerators, on the reagent benches, on desks as paperweights. His two technicians, wearing heavy sweaters under their lab coats, were both eating apples as I entered.

  “Wife,” Murphy said, shaking hands with me. “Makes a specialty. Want one? I have Delicious and Cortland today.”

  “No, thanks,” I said.

  He took a bite from one after polishing it briskly on his sleeve. “Good. Really.”

  “I haven’t got time,” I said.

  “Always in a rush,” Murph said. “Jesus Christ, always in a rush. Haven’t seen you or Judith for months. What’ve you been up to? Terry’s playing guard on the Belmont first eleven.”

  He lifted a picture from his desk and held it under my nose. It showed his son in a football uniform, growling into the camera, looking like Murph: small, but tough.

  “We’ll have to get together soon,” I said to him, “and talk about families.”

  “Ummmm.” Murph devoured his apple with remarkable speed. “Let’s do that. How’s bridge game? Wife and I had an absolutely devastating time last weekend. Two weekends ago. Playing with—”

  “Murph,” I said. “I have a problem.”

  “Probably an ulcer,” Murph said, selecting another apple from a row along his desk. “Nervous guy I know. Always in a rush.”

  “Actually,” I said, “this is right up your alley.”

  He grinned in sudden interest. “Steroids? First time in history a pathologist’s interested in steroids, I bet.” He sat down behind his desk and propped his feet up. “Ready and waiting. Shoot.”

  Murphy’s work concerned steroid production in pregnant women and fetuses. He was located in the BLI for a practical, if somewhat grisly, reason—he needed to be near the source of supply, which in his case was clinic mothers and the occasional stillbirths2 assigned to him.

  “Can you do a hormone test for pregnancy at autopsy?” I asked.

  He scratched his head in swift, nervous, fluttery movements. “Hell. Suppose so. But who’d want to?”

  “I want to.”

  “What I mean is, can’t you tell at autopsy if she’s pregnant or not?”

  “Actually, no, in this case. It’s very confused.”

  “Well. No accepted test, but I imagine it could be done. How far along?”

  “Four months, supposedly.”

  “Four months? And you can’t tell from the uterus?”

  “Murph—”

  “Yeah, sure, it could be done at four months,” he said. “Won’t stand up in a courtroom or anything, but yeah. Could be done.”

  “Can you do it?”

  “That’s all we got in this lab,” he said. “Steroid assays. What’ve you got?”

  I didn’t understand; I shook my head.

  “Blood or urine. Which?”

  “Oh. Blood.” I reached into my pocket and drew out a test tube of blood I had collected at the autopsy. I’d asked Weston if it was O.K., and he said he didn’t care.

  Sometimes rather bitter arguments break out over who needs the next dead baby most for their studies.

  Murph took the tube and held it to the light. He flicked it with his finger. “Need two cc’s,” he said. “Plenty here. No problem.”

  “When will you let me know?”

  “Two days. Assay takes forty-eight hours. This is post blood?”

  “Yes. I was afraid the hormones might be denatured or something…”

  Murph sighed. “How little we remember. Only proteins can be denatured, and steroids are not proteins, right? This’ll be easy. See, the normal rabbit test is chorionic gonadotrophin in urine. But in this lab we’re geared to measure that, or progesterone, or any of a number of other eleven-beta hydroxylated compounds. In pregnancy, progesterone levels increase ten times. Estriol levels increase a thousand times. We can measure a jump like that, no sweat.” He glanced at his technicians. “Even in this lab.”

  One of the technicians took up the challenge. “I used to be accurate,” she said, “before I got frostbite on my fingers.”

  “Excuses, excuses,” Murphy grinned. He turned back to me and picked up the tube of blood. “This’ll be easy. We’ll just pop it onto the old fractionating column and let it perk through,” he said. “Maybe we’ll do two independent aliquots, just in case one gets fouled up. Who’s it from?”

  “What?”

  He waved the test tube in front of me impatiently. “Whose blood?”

  “Oh. Just a case,” I said, shrugging.

  “A four-month pregnancy and you can’t be sure? John boy, not leveling with your old buddy, your old bri
dge opponent.”

  “It might be better,” I said, “if I told you afterward.”

  “O.K., O.K. Far from me to pry. Your own way, but you will tell me?”

  “Promise.”

  “A pathologist’s promise,” he said, standing up, “rings of the eternal.”

  Boston Lying-in Hospital.

  Stillbirths, abortuses, and placentas are in hot demand at the BLI for the dozen or so groups doing hormone research.

  SEVEN

  THE LAST TIME ANYONE COUNTED, there were 25,000 named diseases of man, and cures for 5,000 of them. Yet it remains the dream of every young doctor to discover a new disease. That is the fastest and surest way to gain prominence within the medical profession. Practically speaking, it is much better to discover a new disease than to find a cure for an old one; your cure will be tested, disputed, and argued over for years, while a new disease is readily and rapidly accepted.

  Lewis Carr, while still an intern, hit the jackpot: he found a new disease. It was pretty rare—a hereditary dysgammaglobulinemia affecting the beta-fraction which he found in a family of four—but that was not important. The important thing was that Lewis discovered it, described it, and published his results in the New England Journal of Medicine.

  Six years later he was made clinical professor at the Mem. There was never any question he would be; simply a matter of waiting until somebody on the staff retired and vacated an office.

  Carr had a good office in terms of status at the Mem; it was perfect for a young hotshot internist. For one thing, it was cramped and made even worse by the stacks of journals, texts, and research papers scattered all around. For another, it was dirty and old, tucked away in an obscure corner of the Calder Building, near the kidney research unit. And for the finishing touch, amid the squalor and mess sat a beautiful secretary, looking sexy, efficient, and wholly unapproachable: a nonfunctional beauty to contrast with the functional ugliness of the office.

  “Dr. Carr is making rounds,” she said without smiling. “He asked for you to wait inside.”

  I went in and took a seat, after removing a stack of back issues of the American Journal of Experimental Biology from the chair. A few moments later, Carr arrived. He wore a white lab coat, open at the front (a clinical professor would never button his lab coat) and a stethoscope around his neck. His shirt collar was frayed (clinical professors aren’t paid much), but his black shoes gleamed (clinical professors are careful about things that really count). As usual, his manner was very cool, very collected, very political.

  Unkind souls said Carr was more than political, that he shamelessly sucked up to the senior staff men. But many people resented his swift success and his confident manner. Carr had a round and childlike face; his cheeks were smooth and ruddy. He had an engaging boyish grin that went over very well with the female patients. He gave me that grin now.

  “Hi, John.” He shut the door to his outer office and sat down behind his desk. I could barely see him over the stacked journals. He removed the stethoscope from his neck, folded it, and slipped it into his pocket. Then he looked at me.

  I guess it’s inevitable. Any practicing doctor who faces you from behind a desk gets a certain manner, a thoughtful-probing-inquisitive air which is unsettling if there’s nothing wrong with you. Lewis Carr got that way now.

  “You want to know about Karen Randall,” he said, as if reporting a serious finding.

  “Right.”

  “For personal reasons.”

  “Right.”

  “And anything I tell you goes no further?”

  “Right.”

  “O.K.,” he said. “I’ll tell you. I wasn’t present, but I have followed things closely.”

  I knew that he would have. Lewis Carr followed everything at the Mem closely; he knew more local gossip than any of the nurses. He gathered his knowledge reflexively, the way some other people breathed air.

  “The girl presented in the outpatient ward at four this morning. She was moribund on arrival; when they sent a stretcher out to the car she was delirious. Her trouble was frank vaginal hemorrhage. She had a temperature of 102, dry skin with decreased turgor, shortness of breath, a racing pulse, and low blood pressure. She complained of thirst.”1

  Carr took a deep breath. “The intern looked at her and ordered a cross match so they could start a transfusion. He drew a syringe for a count and crit2 and rapidly injected a liter of D 5.3 He also attempted to locate the source of the hemorrhage but he could not, so he gave her oxytocin to clamp down the uterus and slow bleeding, and packed the vagina as a temporary measure. Then he found out who the girl was from the mother and shit in his pants. He panicked. He called in a resident. He started the blood. And he gave her a good dose of prophylactic penicillin. Unfortunately, he did this without consulting her chart or asking the mother about allergic reactions.”

  “She was hypersensitive.”4

  “Severely,” Carr said. “Ten minutes after giving the penicillin i.m.5 the girl went into choking spasms and appeared unable to breathe despite a patent airway. By now the chart was down from the record room, and the intern realized what he had done. So he administered a milligram of epinephrine i.m. When there was no response, he went to a slow IV, benadryl, cortisone, and aminophylline. They put her on positive pressure oxygen. But she became cyanotic,6 convulsive, and died within twenty minutes.”

  I lit a cigarette and thought to myself that I wouldn’t like to be that intern now.

  “Probably,” Carr said, “the girl would have died anyway. We don’t know that for sure, but there’s every reason to think that at admission her blood loss already approached fifty percent. That seems to be the cut-off, as you know—the shock is usually irreversible. So we probably couldn’t have kept her. Of course, that doesn’t change anything.”

  I said, “Why’d the intern give penicillin in the first place?”

  “That’s a peculiarity of hospital procedure,” Carr said. “It’s a kind of routine around here for certain presenting symptoms. Normally when we get a girl with evidence of a vaginal bleed and a high fever—possible infection—we give the girl a D & C, put her to bed, and stick her a shot of antibiotic. Send her home the next day, usually. And it goes down on the charts as miscarriage.”

  “Is that the final diagnosis on Karen Randall’s record? Miscarriage?”

  Carr nodded. “Spontaneous. We always put it down that way, because if we do that, we don’t have to fool with the police. We see quite a few self-induced or illegally induced abortions here. Sometimes the girls come in with so much vaginal soap they foam like overloaded dishwashers. Other times, it’s bleeding. In every case, the girl is hysterical and full of wild lies. We just take care of it quietly and send her on her way.”

  “And never report it to the police?”7

  “We’re doctors, not law-enforcement officers. We see about a hundred girls a year this way. If we reported every one, we’d all spend our time in court testifying and not practicing medicine.”

  “But doesn’t the law require—”

  “Of course,” Carr said quickly. “The law requires that we report it. The law also requires that we report assaults, but if we reported every drunk who got into a bar brawl, we’d never hear the end of it. No emergency ward reports everything it should. You just can’t operate on that basis.”

  “But if there’s been an abortion—”

  “Look at it logically,” Carr said. “A significant number of these cases are spontaneous miscarriages. A significant number aren’t, but it doesn’t make sense for us to treat it any other way. Suppose you know that the butcher of Barcelona worked on a girl; suppose you call in the police. They show up the next day and the girl tells them it was spontaneous. Or she tells them she tried it on herself. But either way she won’t talk, so the police are annoyed. Mostly, with you, because you called them in.”

  “Does this happen?”

  “Yes,” Carr said, “I’ve seen it happen twice myself. Both times, the girl show
ed up crazy with fear, convinced she was going to die. She wanted to nail the abortionist, so she demanded the police be called in. But by morning, she was feeling fine, she’d had a nice hospital D & C, and she realized her problems were over. She didn’t want to fool with the police; she didn’t want to get involved. So when the cops came, she pretended it was all a big mistake.”

  “Are you content to clean up after the abortionists and let it go?”

  “We are trying to restore people to health. That’s all. A doctor can’t make value judgments. We clean up after a lot of bad drivers and mean drunks, too. But it isn’t our job to slap anybody’s hand and give them a lecture on driving or alcohol. We just try to make them well again.”

  I wasn’t going to argue with him; I knew it wouldn’t do any good. So I changed the subject.

  “What about the charges against Lee? What happened there?”

  “When the girl died,” Carr said, “Mrs. Randall became hysterical. She started to scream, so they gave her a tranquilizer and sedative. After that, she settled down, but she continued to claim that her daughter had named Lee as the abortionist. So she called the police.”

  “Mrs. Randall did?”

  “That’s right.”

  “What about the hospital diagnosis?”

  “It remains miscarriage. This is a legitimate medical interpretation. The change to illegal abortion is made on nonclinical grounds, so far as we are concerned. The autopsy will show whether an abortion was performed.”

  “The autopsy showed it,” I said. “Quite a good abortion, too, except for a single laceration of the endornetrium. It was done by someone with skill—but not quite enough skill.”

  “Have you talked with Lee?”

  “This morning,” I said. “He claims he didn’t do it. On the basis of that autopsy, I believe him.”

  “A mistake—”

  “I don’t think so. Art’s too good, too capable.”