A Case Of Need Part 2

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 finis.h.i.+ng touch, amid the squalor and mess sat a beautiful secretary, looking s.e.xy, 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 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 b.u.t.ton his lab coat) and a stethoscope around his neck. His s.h.i.+rt collar was frayed (clinical professors aren't paid much), but his black shoes gleamed (clinical from the chair. A few moments later, Carr arrived. He wore a white lab coat, open at the front (a clinical professor would never b.u.t.ton his lab coat) and a stethoscope around his neck. His s.h.i.+rt 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 grinnow."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."1 knew that he would have. Lewis Carr followedeverything 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 v.a.g.i.n.al 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. 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 v.a.g.i.n.a as a temporary measure. Then he found out who the girl was from the mother and s.h.i.+t 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." 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 v.a.g.i.n.a as a temporary measure. Then he found out who the girl was from the mother and s.h.i.+t 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."41Thirst is an important symptom in shock. For unknown reasons, it ap pears only in severe shock due to fluid loss, and is regarded as an ominous sign.2White count and hematocrit.3Five percent dextrose in water, used to replace lost fluid volume.4Penicillin reactions occur in 9-10 percent of normal patients.

"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, 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." 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 v.a.g.i.n.al 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. Send5 Intramuscularly. 6 Blue. Blue.

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 v.a.g.i.n.al 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 a.s.saults, 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't7 See Appendix II: Cops and Doctors.

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 showed 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."

Carr removed the stethoscope from his pocket and played with it, looked uncomfortable. "This is a very messy thing," he said. "Very messy."

"It has to be cleared up," I said. "We can't hide our heads in the sand and let Lee go to h.e.l.l.""No, of course not," Carr said. "But J. D. was very upset.""I imagine so."

"He practically killed that poor intern when he saw what treatment had been given. I was there, and I thought he was going to strangle the kid with his bare hands."

"Who was the intern?""Kid named Roger Whiting. Nice kid, even though he went to P & S.""Where is he now?"

"At home, probably. He went off at eight this morning." Carr frowned and fiddled once more with his stethoscope. "John," he said, "are you sure you want to get involved in this?"

"I don't want anything to do with it," I said. "If I had my choice, I'd be back in my lab now. But I don't see any choice.""The trouble is," Carr said slowly, "that this thing has gotten out of control. J. D. is very upset.""You said that before.""I'm just trying to help you understand how things are." Carr rearranged things on his desk and did not look at me. Finally he said, "The case is in the proper hands. And I understand Lee has a good lawyer.""There are a lot of dangling questions. I want to be sure they're all cleaned up.""It's in the proper hands," Carr said again."Whose hands? The Randalls? The goons I saw down at the police station?""We have an excellent police force in Boston," Carr said."Bulls.h.i.+t."He sighed patiently and said, "What can you hope to prove?""That Lee didn't do it."Carr shook his head. "That's not the point.""It seems to me that's precisely the point.""No," Carr said. "The point is that the daughter of J. D. Randall was killed by an abortionist, and somebody has to pay. Lee's an abortionist-that won't be hard to prove in court. In a Boston court, the jury is likely to be more than half Catholic. They'll convict him on general principles.""On general principles?""You know what I mean," Carr said, s.h.i.+fting in his chair."You mean Lee's the goat.""That's right. Lee's the goat.""Is that the official word?""More or less," Carr said."And what are your feelings about it?"

"A man who performs abortions puts himself in danger. He's breaking the law. When he aborts the daughter of a famous Boston physician-"

"Lee says he didn't do it."Carr gave a sad smile. "Does it matter?"

EIGHT.

IT TAKES THIRTEEN YEARS from the time you leave college to the time you become a cardiac surgeon. You have four years of medical school, a year of interns.h.i.+p, three of general surgery, two of thoracic surgery, two of cardiac surgery. Somewhere along the line, you spend two years working for Uncle Sam.1 It takes a certain kind of man to a.s.sume this burden, to set his sights on such a distant goal. By the time he is ready to begin surgery on his own, he has become another person, almost a new breed, estranged by his experience and his dedication from other men. In a sense, that is part of the training: surgeons are lonely men.I thought of this as I looked down through the gla.s.s-overhead viewing booth into OR 9. The booth was built into the ceiling, allowing you a good view of the entire room, the staff, and the procedure. Students and residents often sat up here and watched. There was a microphone in the OR, so that you heard everything-the clink of instruments, the rhythmic hiss of the respirator, the quiet1 See Appendix III: Battlefields and Barberpoles.voices-and there was a b.u.t.ton you could press to talk to the people below. Otherwise they could not hear you.

I had come to this room after going to J. D. Randall's office. I had wanted to see the chart on Karen, but Randall's secretary said she didn't have it. J. D. had it, and J. D. was in surgery now. That had surprised me. I had thought he would have taken the day off, considering. But apparently it had not entered his mind.

The secretary said the operation was probably almost over, but one look through the gla.s.s told me it was not. The chest of the patient was still open and the heart was still incised; they had not even begun suturing. There I was not going to interrupt them; I'd have to come back later to try and get the chart.

But I stayed a moment to watch. There is something compelling about open-heart surgery, something fantastic and fabulous, a mixture of dream and nightmare, all come true. There were sixteen people in the room below me, including four surgeons. Everyone was moving, working, checking in smooth, coordinated movements, like a kind of ballet, like a surrealistic ballet. The patient, draped in green, was dwarfed by the heart-lung machine alongside him, a giant complex as large as an automobile, s.h.i.+ning steel, with smoothly moving cylinders and wheels.

At the head of the patient was the anesthetist, surrounded by equipment. There were several nurses, two pump technicians who monitored the dials and gauges on the machine, nurses, orderlies, and the surgeons. I tried to tell which was Randall, but I could not; in their gowns and masks, they all looked the same, impersonal, interchangeable. That was not true, of course. One of those four men had responsibility for everything, for the conduct of all sixteen workers present. And responsibility for the seventeenth person in that room, the man whose heart was stopped.

In one corner, displayed on a television, was the electrocardiogram. The normal EKG is a briskly bouncing line, with spikes for every heartbeat, every wave of electrical energy that fires the heart muscle. This one was flat: just a meaningless squiggle. That meant that according to one major criterion of medicine, the patient was dead. I looked at the pink lungs through the open chest; they were not moving. The patient was not breathing.

The machine did all that for him. It pumped his blood, oxygenated it, removed the carbon dioxide. In its present form, the machine had been in use for about ten years.The people below me did not seem in awe of the machine or the surgical procedure. They worked matter-of-factly at their jobs. I suppose that was one reason why it all seemed so fantastic.I watched for five minutes without realizing the time. Then I left. Outside, in the corridor, two residents slouched in a doorway, still wearing their caps with their masks hanging loosely around theirnecks. They were eating doughnuts and coffee, and laughing about a blind date.

NINE.

ROGER WHITING, M.D., lived near the hospital in a third-floor walk-up on the sleazy side of Beacon Hill, where they dump the garbage from Louisburg Square. His wife answered the door. She was a plain girl, about seven months' pregnant. She looked worried."What do you want?""I'd like to talk to your husband. My name's Berry. I'm a pathologist at the Lincoln."She gave me a hard suspicious glance. "My husband is trying to sleep. He's been on call for the last two days, and he's tired. He's trying to sleep.""It's very important."A slim young man in white ducks appeared behind her. He looked more than tired; he looked exhausted and afraid. He said, "What is it?""I'd like to talk to you about Karen Randall."

"I've been over it," he said, "a dozen times. Talk to Dr. Carr about it."

"I did."Whiting ran his hands through his hair, then said to his wife, "It's O.K., honey. Get me some coffee, would you?" He turned to me. "Want some coffee?"

"Please," I said.

We sat in the living room. The apartment was small, the furniture cheap and rickety. But I felt at home: it had been only a few years since I had done my own interns.h.i.+p. I knew all about the money problems, the stresses, the h.e.l.lish hours, and the slop work you had to do. I knew about the irritating calls from nurses in the middle of the night, asking you to okay another aspirin for patient Jones. I knew how you could drag yourself out of bed to see a patient and how you could, in the small hours of the morning, make a mistake. I had nearly killed an old man with heart failure when I was an intern. With three hours of sleep during the last two days, you could do anything and not give a d.a.m.n.

"I know you're tired," I said. "I won't stay long.""No, no," he said very earnestly. "Anything I can do to help. 1 mean, now . . ."The wife came in with two cups of coffee. She looked at me angrily. The coffee was weak."My questions," I said, "have to do with the girl when she first arrived. Were you in the ward?""No. I was trying to sleep. They called me.""What time was this?""Almost exactly four.""Describe what happened.""I was sleeping in my clothes, in that little room just off the OPD. I wasn't asleep long when theycalled me; I'd just gotten through putting another IV into a lady who pulls them out. She says she doesn't, but she does." He sighed. "Anyway, when they called me, I was bleary as h.e.l.l. I got up and dunked my head in cold water, then toweled off. When I got to the ward, they were bringing the girl in on a stretcher.""Was she conscious?""Yes, but disoriented. She was pale, and she'd lost a lot of blood. She was feverish and delirious. We couldn't get a good temperature because she kept gnas.h.i.+ng her teeth, so we figured it was about 102 and got to work on the cross-matching.""What else was done?""The nurses got a blanket over her and propped her feet up with shock blocks.1 Then I examined the lesion. It was very clearly v.a.g.i.n.al hemorrhage and we diagnosed it as miscarriage." Then I examined the lesion. It was very clearly v.a.g.i.n.al hemorrhage and we diagnosed it as miscarriage.""About the bleeding," I said, "was there any discharge accompanying it?"He shook his head. "Just blood.""No tissue? No signs of a placenta?""No. But she'd been bleeding for a long time. Her clothes . . ." He looked across the room, seeing it again in his mind. "Her clothes were very heavy. The nurses had trouble getting them off.""During this time, did the girl say anything coherent?"

1 Shock blocks are simply wooden blocks used to elevate the legs in cases of shock, helping to get blood to the head.

"Not really. She was mumbling every once in a while. Something about an old man, I think. Her old man, or an old man. But it wasn't clear, and n.o.body was really paying any attention."

"Did she say anything else?"He shook his head. "Just when they were cutting her clothes off her. She would try to pull them back. Once she said 'You can't do this to me.' And then later she said, 'Where am I?' But that was just delirious talk. She wasn't really coherent.""What did you do about the bleeding?""I tried to localize it. It was hard, and things were pretty rushed. And we couldn't angle the lights down properly. Finally I decided to pack it with gauze pads and concentrate on getting her blood volume back up.""Where was Mrs. Randall during all this?""She waited by the door. She seemed all right until we had to tell her what had happened. Then she went to pieces. Just went to pieces.""What about Karen's records? Had she ever been admitted to the hospital before?""I didn't see her chart," he said, "until . . . later. They had to be pulled from the record room. But she had been in before. Papp smears every year since she was fifteen. Usual blood tests from her twice-yearly physicals. She was well looked after medically, as you might expect.'"Was there anything unusual in her past history? Besides the hypersensitivity, I mean."He gave a sad smile. "Isn't that enough?"For a fleeting moment I was angry with him. He was soaking in self-pity, despite his natural fright. But I wanted to tell him he'd better get used to the idea of people dying in front of him, lots of people. And he'd better get used to the idea that he could make a mistake, because they happened. Sometimes the mistakes were balder than others, but it was just degree. I wanted to tell him if he'd asked Mrs. Randall about Karen's hypersensitivity, and she'd said the girl was O.K., that Whiting would have been free and clear. The girl would still have died, of course, but Whiting would be clear. His mistake was not killing Karen Randall; it was not asking permission first.I thought about saying this, but I didn't."Any indication in the chart of psychiatric problems?" I asked."No.""Nothing unusual at all?""No." Then he frowned. "Wait a minute. There was one strange thing. A complete set of skull films were ordered about six months ago.""Did you see the films?""No. I just read the radiologist's dx.""And what was that?""Normal. No pathology.""Why were the films taken?""It didn't say."

"Was she in an accident of some kind? A fall, or an auto accident?"

"Not that I know of.""Who ordered the films?"

"Probably Dr. Randall. Peter Randall, that is. He was her doctor."

"And you don't know why the X rays were taken?""No.""But there must be a reason," I said."Yes," he said, but he didn't seem very interested. He stared moodily at his coffee, then sipped it. Finally he said, "I hope they take that abortionist and screw him to the wall. Whatever he gets, he deserves worse."I stood. The boy was under stress and almost on the verge of tears. All he could see was a promising medical career jeopardized because he had made a mistake with the daughter of a prominent physician. In his anger and frustration and self-pity, he, too, was looking for a goat. And he needed one worse than most."Are you planning to settle in Boston?" I asked. "I was," he said with a wry look.WHEN ILEFT THE INTERN I called Lewis Carr. I wanted to see Karen Randall's chart more than ever. I had to find out about those X rays."Lew," I said, "I'm going to need your help again.""Oh?" He sounded thrilled by the prospect."Yes. I've got to get her chart. It's imperative.""I thought we went over that.""Yes, but something new has come up. This thing is getting crazier by the minute. Why were X rays ordered--""I'm sorry," Carr said. "I can't help you.""Lew, even if Randall does have the chart, he cant keep--""I'm sorry, John. I'm going to be tied up here for the rest of the day and most of tomorrow. I'm just not going to have time."He was speaking formally, a man counting his words, repeating the sentences over to himself before speaking them aloud."What happened? Randall get to you and b.u.t.ton your mouth?""I feel," Carr said, "that the case should be left in the hands of those best equipped to deal with it. I'm not, and I don't think other doctors are, either."I knew what he was saying and what he meant. Art Lee used to laugh about the elaborate way doctors back out of things, leaving behind a spoor of double-talk. Art called it The Pilate Maneuver."O.K.," I said, "if that's the way you feel."I hung up.

In a way, I should have expected it. Lewis Carr always played the game, following all the rules just like a good boy. That was the way he always had been, and the way he always would be.

TEN.

MY ROUTE FROM WHITING to the medical school took me past the Lincoln Hospital. Standing out in front near the taxi stand was Frank Conway, hunched over, his hands in his pockets, looking down at the pavement. Something about his stance conveyed sadness and a deep, dulling fatigue. I pulled over to the curb.

"Need a ride?""I'm going to Children's," he said. He seemed surprised that I had stopped. Conway and I aren't close friends. He is a fine doctor but not pleasant as a man. His first two wives had divorced him, the second after only six months."Children's is on the way," I said.It wasn't, but I'd take him anyway. I wanted to talk to him. He got in and I pulled out into traffic."What takes you to Children's?" I said."Conference. They have a congenital CPC once a week. You?""Just a visit," I said. "Lunch with a friend."He nodded and sat back. Conway was young, only thirty-five. He had breezed through his residencies, working under the best men in the country. Now he was better than any of them, or so itwas said. You couldn't be sure about a man like Conway: he was one of the few doctors who become so famous so fast that they take on some aspects of politicians and movie stars; they acquire blindly loyal fans and blindly antagonistic critics; one either loves them or loathes them. Physically, Conway was a commanding presence, a stocky, powerful man with gray-flecked hair and deep, piercing blue eyes."I wanted to apologize," Conway said, "about this morning. I didn't mean to blow up that way.""It's O.K.""I have to apologize to Herbie. I said some things ...""He'll understand."

"I feel like h.e.l.l," Conway said. "But when you watch a patient just collapse under you, just fall apart before your very eyes. . . . You don't know how it is."

"I don't," I admitted.We drove for a while in silence, then I said, "Can I ask you a favor?" Sure."Tell me about J. D. Randall."He paused. "Why?""Just curious.""Bulls.h.i.+t.""All right," I said."They got Lee, didn't they?" Conway said."Yes.""Did he do it?""No.""Are you sure?"

"I believe what he tells me," 1 said. Conway sighed. "John," he said, "you're not a fool. Suppose somebody hung this thing on you. Wouldn't you deny it?" "That's not the question." "Sure it is. Anybody'd deny it." "Isn't it possible Art didn't do it?" "It's not merely possible. It's likely." "Well then?"

Conway shook his head. "You're forgetting the way it works. J. D. is a big man. J. D. lost a daughter. There happens to be a convenient Chinaman in the neighborhood, who is known to do the nasty deed. A perfect situation.""I've heard that theory before. I don't buy it." "Then you don't know J. D. Randall." "That's true.""J. D. Randall," Conway said, "is the arch-p.r.i.c.k of the universe. He has money and power and prestige. He can have whatever he wants-even a little Chinaman's head."I said, "But why should he want it?" Conway laughed. "Brother, where have you been?"I must have looked puzzled. "Don't you know about . . ." He paused, seeing that I did not. Then he very deliberately folded his arms across his chest and said nothing. He stared straight ahead."Well?" I said."Better ask Art.""I'm asking you," I said."Ask Lew Carr,' Conway said. "Maybe he'll tell you. I won't.""Well then," I said, "tell me about Randall.""As a surgeon.""All right, as a surgeon."Conway nodded. "As a surgeon," he said, "he isn't worth s.h.i.+t. He's mediocre. He loses people he shouldn't lose. Young people. Strong people."I nodded."And he's mean as h.e.l.l. He chews out his residents, puts them through all sorts of c.r.a.p, keeps them miserable. He has a lot of good young men working under him, and that's how he controls them. I know; I did two years of thoracic under Randall before I did my cardiac at Houston. I was twenty-nine when I first met Randall, and he was forty-nine. He comes on very strong with his busy manner and his Bond Street suits and his friends with chateaux in France. None of it means he's a good surgeon, of course, but it carries over. It throws a halo around him. It makes him look good."

I said nothing. Conway was warming to his subject, raising his voice, moving his strong hands. I didn't want him to stop.

"The trouble," Conway said, "is that J. D. is in the old line. He started surgery in the forties and fifties, with Gross and Chartriss and Shackleford and the boys. Surgery was different then; manual skill was important and science didn't really count. n.o.body knew about electrolytes or chemistry, and Randall's never felt comfortable with it. The new boys are; they've been weaned on enzymes and serum sodium. But it's all a troublesome puzzle to Randall."

"He has a good reputation," I said."So did John Wilkes Booth," Conway said. "For a while.""Do I sense a professional jealousy?""I can cut circles around him with my left hand," Conway said. "Blindfolded."I smiled."And hung over," he added. "On a Sunday.""What's he like personally?""A p.r.i.c.k. Just a p.r.i.c.k. The residents say he walks around with a hammer in his pocket and a half-dozen nails, just in case he sees the opportunity to crucify somebody.""He can't be that unpleasant.""No," Conway admitted. "Not unless he's in especially good form. Like all of us, he has his off days."'You make him sound very grim.'"No worse than the average b.a.s.t.a.r.d," he said. "You know, the residents say something else, too.""Oh?""Yes. They say J. D. Randall likes cutting hearts because he never had one of his own."ELEVENNO ENGLISHMAN IN HIS RIGHT MIND would ever go toBoston, particularly in 1630. To embark on a long sea journey to a hostile wilderness took more than courage, more than fort.i.tude-it required desperation and fanaticism. Above all it required a deep and irreconcilable break with English society.Fortunately, history judges men by their actions, not their motivations. It is for that reason that Bostonians can comfortably think of their ancestors as proponents of democracy and freedom, Revolutionary heroes, liberal artists and writers. It is the city of Adams and Revere, a city that still cherishes the Old North Church and Bunker Hill.

But there is another face to Boston, a darker face, which lies hidden in the pillory, the stocks, the dunking stool, and the witch hunts. Hardly a man now alive can look at these devices of torture for what they are: evidences of obsession, neurosis, and perverse cruelty. They are proofs of a society encircled by fear of sin, d.a.m.nation, h.e.l.lfire, disease, and Indians-in roughly that order. A tense, fearful, suspicious society. In short, a society of reactionary religious fanatics.

There is also a geographical factor, for Boston was once a swamp. Some say this accounts for its outstandingly bad weather and uniformly humid climate; others say it is unimportant.

Bostonians are inclined to overlook much of the past. Like a slum kid who makes good, the city has swung far from its origins, and attempted to conceal them. As a colony of common men, it has established an unt.i.tled aristocracy to rival the most ancient and rigid of Europe. As a city of religion, it has developed a scientific community unrivaled in the East. It is also strongly narcissistic-a trait it shares with another city of questionable origin, San Francisco.Unfortunately for both these cities, they can never quite escape their past. San Francisco cannot quite shake off its booming, crude, gold-rush spirit to become a genteel Eastern town. And Boston, no matter how hard it tries, cannot quite elude Puritanism and become English again.We are all tied to the past, individually and collectively. The past shows through in the very structure of our bones, the distribution of our hair, and the coloring of our skin, as well as the way we walk, stand, eat, dress-and think.I was reminded of this as I went to meet William Harvey Shattuck Randall, student of medicine.ANYONE NAMED AFTER WILLIAM HARVEY1 to say nothing of William Shattuck, must feel like a d.a.m.ned to say nothing of William Shattuck, must feel like a d.a.m.ned1 The English court physician who, in 1628, discovered that blood circulated in a closed loop.fool. Like being named after Napoleon or Cary Grant, it places too great a burden on a child, too much of a challenge. Many things in life are difficult to live down, but nothing is more difficult than a name.George Gall is a perfect example. After medical school, where he suffered through countless jokes and puns, he became a surgeon, specializing in liver and gallbladder disease. It was the worst possible thing he could do with a name like that, but he went into it with a strange, quiet certainty, as if it had all been foreordained. In a sense perhaps it had. Years later, when the jokes began to wear very thin, he wished he could change his name, but that was impossible.2I doubted that William Harvey Shattuck Randall would ever change his own name. Though a liability, it was also an a.s.set, particularly if he remained in Boston; besides, he seemed to be bearing up well. He was husky and blond and open-faced in a pleasant way. There was an Ail-American wholesomeness about him which made his room incongruous and faintly ridiculous.William Harvey Shattuck Randall lived on the first floor of Sheraton Hall, the medical-school dormitory. Like most rooms in the dorm, his was a single, though rather more s.p.a.cious than most. Cer- 2 A doctor cannot change his name after receiving his M.D. degree without invalidating that degree. This means that there is a great rush in the final weeks of med school among doctors flocking into court to change their names before they receive their diplomas.

tainly more s.p.a.cious than the fourth-floor pigeonhole I had occupied when I was a student. The top-floor rooms are cheaper.

They'd changed the paint color since my day. It was dinosaur-egg gray, then; now it was vomit green. But it was still the same old dorm-the same bleak corridors, the same dirty stairs, the same stale odor of sweat socks, textbooks, and hexachlorophene.Randall had fixed his room up nicely. The decor was antique; the furniture looked as if it had been bought at a Versailles auction. There was a faded, nostalgic splendor about it, with its tattered red velvet and chipped gilded wood.Randall stood back from the door. "Come in," he said. He didn't ask who I was. He had taken one look and smelled doctor. You get so you can do it, when you've been around them long enough.I came into the room and sat down."Is it about Karen?" He seemed more preoccupied than sad, as if he had just returned from something important or were about to leave."Yes," I said. "I know this is a bad time . . .""No, go ahead."I lit a cigarette and dropped the match into a gilded Venetian-gla.s.s ashtray. It was ugly but expensive."I wanted to talk to you about her." Sure.I kept waiting for him to ask who I was, but he didn't really seem to care. He sat down in an arm-chair across from me, crossed his legs, and said, "What do you want to know?""When did you see her last?""Sat.u.r.day. She came in from Northampton on the bus, and I picked her up at the terminal after lunch. I had a couple of hours free. I drove her out to the house.""How did she seem?"He shrugged. "Fine. There was nothing wrong with her, she seemed very happy. Talked all about Smith and her roommate. Apparently she had this wild roommate. And she talked about clothes, that sort of thing.""Was she depressed? Nervous?""No. Not at all. She acted the same as always. Maybe a little excited about coming home after being away. I think she was a little worried about Smith. My parents treat her as the baby of the family, and she thought they didn't have confidence in her ability to make it. She was a little . . . defiant, I guess you'd say.""When did you see her before last Sat.u.r.day?""I don't know. Not since late August, I guess.""So this was a reunion."

"Yes," he said. "I was always glad to see her. She was very bubbly, with a lot of energy, and she was a good mimic. She could give you an imitation of a professor or a boyfriend and she was hysterical. In fact, that was how she got the car."

"The car?"

"Sat.u.r.day night," he said. "We were all at dinner. Karen, myself, Ev, and Uncle Peter.""Ev?""My stepmother," he said. "We all call her Ev.""So there were five of you?""No, four.""What about your father?""He was busy at the hospital."He said it very matter-of-factly, and I let it drop.

"Anyway," William said, "Karen wanted a car for the weekend and Ev refused, saying she didn't want her to be out all night. So Karen turned to Uncle Peter, who is a softer touch, and asked if she could borrow his car. He was reluctant, so she threatened to imitate him, and he immediately loaned her the car.

"What did Peter do for transportation?""I dropped him off at his place that night, on my way back here.""So you spent several hours with Karen on Sat.u.r.day.""Yes. From around one o'clock to nine or ten.""Then you left with your uncle?""Yes.""And Karen?""She stayed with Ev.""Did she go out that night?""I imagine so. That was why she wanted the car.""Did she say where she was going?""Over to Harvard. She had some friends in the college.""Did you see her Sunday?""No. Just Sat.u.r.day.""Tell me," I said, "when you were with her-did she look any different to you?"He shook his head. "No. Just the same. Of course, she'd put on a little weight, but I guess all girls do that when they go to college. She was very active in the summer, playing tennis and swimming. She stopped that when she got to school, and I guess she put on a few pounds." He smiled slowly. "We kidded her about it. She complained about the lousy food, and we kidded her about eating so much of it that she still gained weight.""Had she always had a weight problem?""Karen? No. She was always a skinny little kid, a real tomboy. Then she filled out in a real hurry. It was like a caterpillar, you know, and the coc.o.o.n.""Then this was the first time she'd ever been overweight?"He shrugged. "I don't know. To tell you the truth, I never paid that much attention.""Was there anything else you noticed?""No, nothing else."

I looked around the room. On his desk, next to copies of Robbins' copies of Robbins' Pathology and Surgical Anatomy, Pathology and Surgical Anatomy, was a photograph of the two of them. They both looked tanned and healthy. He saw me looking and said, "That was last spring, in the Bahamas. For once the whole family managed to get a week off together. We had a great time." was a photograph of the two of them. They both looked tanned and healthy. He saw me looking and said, "That was last spring, in the Bahamas. For once the whole family managed to get a week off together. We had a great time."

I got up and took a closer look. It was a flatteringpicture of her. Her skin was darkly tanned, contrasting nicely with her blue eyes and blonde hair.

"I know it's a peculiar question," I said, "but has your sister always had dark hair on her lips and arms?"

"That was funny," he said, in a slow voice. "Now that you mention it. She had just a little bit there, on Sat.u.r.day, Peter told her she'd better bleach it or wax it. She got mad for a couple of minutes, and then she laughed."

"So it was new?""I guess so. She might have had it all along, but I never noticed it until then. Why?""I don't know," I said.He stood and came over to the picture. "You'd never think she would be the type for an abortion," he said. "She was such a great girl, funny and happy and full of energy. She had a real heart of gold. I know that sounds stupid, but she did. She was kind of the family mascot, being the youngest. Everybody loved her."I said, "Where was she this summer?"He shook his head. "I don't know.""You don't know?""Well, not exactly. In theory, Karen was on the Cape, working in an art gallery in Provincetown." He paused. "But I don't think she was there much. I think she spent most of her time on the Hill. She had some kooky friends there; she collected oddball types.""Men friends? Women friends?""Both." He shrugged. "But I don't really know. She only mentioned it to me once or twice, in casual references. Whenever I tried to ask her about it, she'd laugh and change the subject. She was very clever about discussing only what she wanted to.""Did she mention any names?"

"Probably, but I don't remember. She could be maddening about names, talking about people casually as if you knew them intimately. Using just their first names. It was no good reminding her that you'd never heard of Herbie and Su-su and Allie before." He laughed. "I do remember she once did an imitation of a girl who blew bubbles."

"But you can't remember any names?"He shook his head. "Sorry."I stood to go. "Well," I said, "you must be very tired. What are you on these days?""Surgery. We just finished OB-GYN.""Like it?""It's O.K.," he said blandly.

As I was leaving, I said, "Where did you do your OB?"

"At the BLI." He looked at me for a moment and frowned. "And to answer your question, I a.s.sisted on several. I know how to do one. But I was on duty at the hospital Sunday night. All night long. So there it is."

"Thanks for your time," I said."Sure," he said.AS ILEFT THE DORMITORY, I saw a tall, lean, silver-haired man walking toward me. Of course I recognized him, even from a distance.J. D. Randall was, if nothing else, distinctive.TWELVE THE SUN WAS SETTING, and the light on the quadrangle was turning yellow-gold. I lit a cigarette and walked up to Randall. His eyes widened slightly as he saw me, and then he smiled.

"Dr. Berry."Very friendly. He held out his hand. I shook it: dry, clean, scrubbed to two inches above the elbow for ten minutes. A surgeon's hand."How do you do, Dr. Randall."He said, "You wanted to see me?"I frowned."My secretary," he said, "told me you had stopped by my office. About the chart.""Oh, yes," I said, "the chart."He smiled benignly. He was half a head taller than I. "I think we had better clear up a few things.""All right.""Come with me."He didn't intend it as a command, but it came out that way. I was reminded that surgeons were the last autocrats in society, the last cla.s.s of men who were given total control over a situation. Surgeons a.s.sumed the responsibility for the welfare of the patient, the staff, everything.

We walked back toward the parking lot. I had the feeling that he had come especially to see me. I had no idea how he knew I was there, but the feeling was very strong. As he walked, he swung his arms loosely at his sides. For some reason, I watched them; I remembered the neurologist's law of swinging arms.1 I saw his hands, which were huge, all out of proportion to the rest of his body, huge hands, thick and hairy and red. His nails were trimmed to the required one-millimeter surgical length. His hair was cut short and his eyes were cold, gray, and businesslike. I saw his hands, which were huge, all out of proportion to the rest of his body, huge hands, thick and hairy and red. His nails were trimmed to the required one-millimeter surgical length. His hair was cut short and his eyes were cold, gray, and businesslike.

"Several people have mentioned your name to me lately," he said."Oh?""Yes."We came into the parking lot. His car was a silver Porsche; he stopped beside it and leaned casually against the polished fender. Something about his manner told me I was not invited to do the same. He looked at me for a moment in silence, his eyes flicking over my face, and then he said, "They speak highly of you.""I'm glad to hear that.""A man of good judgment and good sense."1 A paralyzed man will swing a paralyzed arm less than a good arm.

I shrugged. He smiled at me again, then said, "Busy day?"

"Busier than some days.""You're at the Lincoln, is that right?""Yes.""You're well thought of there.""I try to do a good job.""I'm told your work is excellent.""Thank you." His approach was throwing me off; I didn't see where he was going. I didn't have to wait long."Did you ever think of changing hospitals?""What do you mean?""There may be other . . . possibilities. Openings.""Oh?""Indeed.""I'm quite happy where I am.""For the present," he said."Yes, for the present.""Do you know William Sewall?"William Sewall was chief pathologist of the Mem. He was sixty-one and would shortly retire. I found myself disappointed in J. D. Randall. The last thing I had expected him to be was obvious."Yes, I know Sewall," I said. "Slightly.""He will soon retire-""Timothy Stone is second man there, and he's excellent.""I suppose," Randall said. He stared up at the sky. "I suppose. But many of us are not happy with him.""I hadn't heard that."He smiled thinly. "It isn't widely known.""And many of you would be happier with me?""Many of us," Randall said carefully, "are looking for a new man. Perhaps someone from the outside, to bring a new viewpoint to the hospital. Change things around a bit; shake things up.""Oh?""That is our thinking," Randall said."Timothy Stone is a close friend," I said."I don't see the relevance of that.""The relevance," I said, "is that I wouldn't screw him.""I would never suggest that you do.""Really?""No," Randall said."Then maybe I'm missing the point," I said.He gave his pleasant smile. "Maybe you are.""Why don't you explain?"He scratched the back of his head reflectively. I could see he was about to change tactics, to try a different approach. He frowned.

"I'm not a pathologist, Dr. Berry," he said, "but I have some friends who are."

"Not Tim Stone, I'll bet."

"Sometimes I think pathologists work harder than surgeons, harder than anyone. Being a pathologist seems to be a full-time job."

"That may be right," I said.

"I'm surprised you have so much free time," he said.

'"Well, you know how it is," I said. I was beginning to be angry. First the bribe, then the threat. Buy him off or scare him off. But along with my anger, I had a strange curiosity: Randall was not a fool, and I knew he wouldn't be talking this way to me unless he was afraid of something. 1 wondered for a moment whether he had done the abortion himself, and then he said, "You have a family?""Yes," I said."Been in Boston some time?""I can always leave," I said, "if I find the pathological specimens too distasteful."He took that very well. He didn't move, didn't s.h.i.+ft his weight on the fender of the car. He just looked at me with those gray eyes and said, "I see.""Maybe you'd better come right out and tell me what's on your mind."