Artropods and Human Disease 3 page

Seddons looked over at the body on the table. “Ah, more business!”

McNeil gestured to the case papers and Seddons picked them up. He asked, “What did he die of?” Then, as he read on, “Coronary, eh?”

McNeil answered, “That’s what it says.”

“You doing this one?”

The resident shook his head. “Pearson’s coming.”

Seddons looked up quizzically. “The boss man himself? What’s special about this case?”

“Nothing special.” McNeil snapped a four-page autopsy form onto a clip board. “Some of the student nurses are coming in to watch. I think he likes to impress them.”

“A command performance!” Seddons grinned. “This I must see.”

“In that case you may as well work.” McNeil passed over the clip board. “Fill in some of this stuff, will you?”

“Sure.” Seddons took the clip board and began to make notes on fee condition of the body. He talked to himself as he worked. “That’s a nice clean appendix scar. Small mole on the left arm.” He moved the arm to one side. “Excuse me, old man.” He made a note, “Slight rigor mortis.” Lifting the eyelids, he wrote, “Pupils round, 0.3 cm. diameter.” He pried the already stiff jaw open, “Let’s have a look at the teeth.”

From the corridor outside there was the sound of feet. Then the autopsy-room door opened, and a nurse, whom McNeil recognized as a member of the nursing school’s teaching staff, looked in. She said, “Good morning, Dr. McNeil.” Behind her was a group of young student nurses.

“Good morning.” The resident beckoned. “You can all come in.”

The students filed through the doorway. There were six, and as they entered all glanced nervously at the body on the table. Mike Seddons grinned. “Hurry up, girls. You want the best seats; we have ’em.”

Seddons ran his eye appraisingly over the group. There were a couple of new ones here he had not seen previously, including the brunette. He took a second look. Yes indeed; even camouflaged by the spartan student’s uniform, it was obvious that here was something special. With apparent casualness he crossed the autopsy room, then, returning, managed to position himself between the girl he had noticed and the rest of the group. He gave her a broad smile and said quietly, “I don’t remember seeing you before.”

“I’ve been around as long as the other girls.” She looked at him with a mixture of frankness and curiosity, then added mockingly, “Besides, I’ve been told that doctors never notice first-year nursing students anyway.”

He appeared to consider. “Well, it’s a general rule. But sometimes we make exceptions—depending on the student, of course.” His eyes candidly admiring, he added, “By the way, I’m Mike Seddons.”

She said, “I’m Vivian Loburton,” and laughed. Then, catching a disapproving eye from the class instructor, she stopped abruptly. Vivian had liked the look of this redheaded young doctor, but it did seem wrong somehow to be talking and joking in here. After all, the man on the table was dead. He had just died, she had been told upstairs; that was the reason she and the other student nurses had been taken from their work to watch the autopsy. The thought of the word “autopsy” brought her back to what was to happen here. Vivian wondered how she was going to react; already she felt uneasy. She supposed, as a nurse, she would grow used to seeing death, but at the moment it was still new and rather frightening.

There were footsteps coming down the corridor. Seddons touched her arm and whispered, “We’ll talk again—soon.” Then the door was flung open and the student nurses moved back respectfully as Dr. Joseph Pearson strode inside. He greeted them with a crisp “Good morning.” Then, without waiting for the murmured acknowledgments, he strode to a locker, slipped off his white coat, and thrust his arms into a gown which he had taken from the shelf. Pearson gestured to Seddons, who stepped over and tied the gown strings at the back. Then, like a well-drilled team, the two moved over to a washbasin where Seddons shook powder from a can over Pearson’s hands, afterward holding out a pair of rubber gloves into which the older man thrust his fingers. All this had been accomplished in silence. Now Pearson shifted his cigar slightly and grunted a “Thanks.”

He crossed to the table and, taking the clip board which McNeil held out to him, began to read it, apparently oblivious of everything else. So far Pearson had not even glanced at the body on the table. Watching the performance covertly, as he, too, moved across, it occurred to Seddons that it was like the entry of a maestro before a symphony. All that was missing was applause.

Now that Pearson had digested the case history he, too, inspected the body, comparing his findings with the notes Seddons had written. Then he put the clip board down and, removing his cigar, faced the nurses across the table. “This is your first experience of an autopsy, I believe.”

The girls murmured, “Yes, sir,” or, “Yes, Doctor.”

Pearson nodded. “Then I will explain that I am Dr. Pearson, the pathologist of this hospital. These gentlemen are Dr. McNeil, the resident in pathology, and Dr. Seddons, a resident in surgery, in his third year . . .” He turned to Seddons. “Am I right?”

Seddons smiled. “Quite right, Dr. Pearson.”

Pearson continued, “In his third year of residency, and who is favoring us with a spell of duty in Pathology.” He glanced at Seddons. “Dr. Seddons will shortly qualify to practice surgery and be released upon an unsuspecting public.”

Two of the girls giggled; the others smiled. Seddons grinned; he enjoyed this. Pearson never missed an opportunity to take a dig at surgeons and surgery, probably with good reason—in forty years of pathology the old man must have uncovered a lot of surgical bloopers. He glanced across at McNeil. The resident was frowning. He doesn’t approve, Seddons thought. Mac likes his pathology straight. Now Pearson was talking again.

“The pathologist is often known as the doctor the patient seldom sees. Yet few departments of a hospital have more effect on a patient’s welfare.”

Here comes the sales pitch, Seddons thought, and Pearson’s next words proved him right.

“It is pathology which tests a patient’s blood, checks his excrements, tracks down his diseases, decides whether his tumor is malignant or benign. It is pathology which advises the patient’s physician on disease and sometimes, when all else in medicine fails”—Pearson paused, looked down significantly at the body of George Andrew Dunton, and the eyes of the nurses followed him—“it is the pathologist who makes the final diagnosis.”

Pearson paused again. What a superb actor the old man is, Seddons thought. What an unabashed, natural ham!

Now Pearson was pointing with his cigar. “I draw your attention,” he was saying to the nurses, “to some words you will find on the wall of many autopsy rooms.” Their eyes followed his finger to the framed maxim thoughtfully provided by a scientific supply house—Mortui Vivos Docent. Pearson read the Latin aloud, then translated. “The dead teach the living.” He looked down again at the body. “That is what will happen now. This man apparently”—he emphasized the word “apparently”—“died of coronary thrombosis. By autopsy we shall discover if that is true.”

At this Pearson took a deep draw on his cigar, and Seddons, knowing what was coming, moved nearer. He himself might be only a bit player in this scene, but he had no intention of missing a cue. As Pearson exhaled a cloud of blue smoke, he handed the cigar to Seddons who took it and placed it down, away from the table. Now Pearson surveyed the instruments laid out before him and selected a knife. With his eye he calculated where he would cut, then swiftly, cleanly, deeply, applied the sharp steel blade.

McNeil was watching the student nurses covertly. An autopsy, he reflected, would never be recommended viewing for the fainthearted, but even to the experienced the first incision is sometimes hard to take. Until this point the body on the table has at least borne physical resemblance to the living. But after the knife, he thought, no illusions are possible. This was not a man, a woman, a child, but merely flesh and bone, resembling life, yet not of life. This was the ultimate truth, the end to which all must come. This was the fulfillment of the Old Testament, “For dust thou art, and unto dust shalt thou return.”

Using the skill, ease, and speed of long experience, Pearson began the autopsy with a deep “Y” incision. With three strong knife strokes he brought the top two branches of the “Y” from each shoulder of the body to meet near the bottom of the chest. Then from this point he cut downward, opening the belly all the way from chest to genitals. There was a hissing, almost a tearing sound, as the knife moved and the flesh parted, revealing a layer of yellow fat beneath the surface.

Still watching the student nurses, McNeil saw that two were deathly white, a third had gasped and turned away; the other three were stoically watching. The resident kept his eye on the pale ones; it was not unusual for a nurse to keel over at her first autopsy. But these six looked as if they were going to be all right; the color was coming back to the two he had noticed, and the other girl had turned back, though with a handkerchief to her mouth. McNeil told them quietly: “If any of you want to go out for a few minutes, that’s all right. The first time’s always a bit hard.” They looked at him gratefully, though no one moved. McNeil knew that some pathologists would never admit nurses to an autopsy until the first incision had been made. Pearson, though, did not believe in shielding anyone. He felt they should see the whole thing from the beginning, and it was something McNeil agreed with. A nurse had to witness a lot of things that were tough to take—sores, mangled limbs, putrefaction, surgery; the sooner she learned to accept the sights and smells of medicine, the better for everyone, including herself.

Now McNeil slipped on his own gloves and went to work with Pearson. By this time, moving swiftly, the older man had peeled back the chest flap and, hacking the flesh loose with a larger knife, exposed the ribs. Next, using the sharp levered rib cutters, he cut his way into the rib cage, exposing pericardium and lungs. The gloves, instruments, and table were now beginning to be covered with blood. Seddons, gloved also, on his side of the table, was cutting back the lower flaps of flesh and opening the abdomen. He crossed the room for a pail and began to remove stomach and intestines, which he put into the pail after studying them briefly. The odor was beginning to be noticeable. Now Pearson and Seddons together tied off and cut the arteries so the undertaker would have no trouble when it came to embalming. Taking a small tube from a rack above the table, Seddons turned on a tap and began to siphon blood that had escaped into the abdomen and, after a nod from Pearson, did the same thing for the chest.

Meanwhile McNeil had applied himself to the head. First he made an incision across the vertex of the skull, starting slightly behind each ear and cutting above the hairline so the mark would not be visible if the body were placed on view by the dead man’s family. Then, using all the strength in his fingers, he peeled the scalp forward in one piece, so that all the flesh from the head was bunched over, the front of the face, covering the eyes. The entire skull was now exposed, and McNeil picked up the portable electric saw which was already plugged in. Before he switched it on he looked over at the student nurses to find them watching him with a mixture of incredulity and horror. Take it easy, girls, he thought; in a few minutes you’ll have seen it all.

Pearson was carefully removing the heart and lungs when McNeil applied the saw to bone. The metallic “scrunch” of the oscillating steel teeth biting into the skull cut grimly across the quiet room. Glancing up, he saw the girl with the handkerchief flinch; if she was going to vomit he hoped it wouldn’t be in here. He kept the blade cutting until the top of the skull was severed. He put down the saw. George Rinne would remove the blood from it when he cleaned all the instruments later. Now McNeil carefully pried loose the skull, exposing the soft membrane covering the brain beneath. Again he glanced at the nurses. They were standing up to it well; if they could take this they could take anything.

With the bony portion of the skull removed, McNeil took sharp scissors and opened the large vein—the superior sagittal sinus—which ran from front to rear along the center of the membrane. The blood poured out, spilling over the scissors and his fingers. It was fluid blood, he noted; there was no sign of thrombosis. He inspected the membrane carefully, then cut and lifted it clear to expose the mass of brain beneath. Using a knife, he carefully severed the brain from the spinal cord and eased it out. Seddons joined him, holding a glass jar half full of formalin, and McNeil gently lowered the brain into it.

Watching McNeil, his hands steady and competent, Seddons found himself wondering again what went on in the pathology resident’s mind. He had known McNeil for two years, first as a fellow resident, though senior to himself in the hospital’s pyramid system, and then more closely during his own few months in Pathology. Pathology had interested Seddons; he was glad, though, it was not his own chosen specialty. He had never had second thoughts about his personal choice of surgery and would be glad when he went back to it in a few weeks’ time. In contrast to this domain of the dead the operating room was a territory of the living. It was pulsing and alive; there was a poetry of motion, a sense of achievement he knew he could never find here. Each to his own, he thought, and pathology for the pathologists.

There was something else about pathology. You could lose your sense of reality, your awareness that medicine was of and for human beings. This brain now . . . Seddons found himself acutely aware that just a few hours ago it was the thinking center of a man. It had been coordinator of the senses—touch, smell, sight, taste. It had held thoughts, known love, fear, triumph. Yesterday, possibly even today, it could have told the eyes to cry, the mouth to drool. He had noticed the dead man was listed as a civil engineer. This, then, was a brain that had used mathematics, understood stresses, devised construction methods, perhaps had built houses, a highway, a water works, a cathedral—legacies from this brain for other humans to live with and use. But what was the brain now?—just a mass of tissue, beginning to be pickled and destined only to be sliced, examined, then incinerated.

Seddons did not believe in God and he found it hard to understand how educated people could. Knowledge, science, thought—the more these advanced, the more improbable all religions became. But he did believe in what, for lack of better phrases, he thought of as “the spark of humanity, the credo of the individual.” As a surgeon, of course, he would not always deal with individuals; nor would he always know his patients, and even when he did he would lose awareness of them in concentrating on problems of technique. But long ago he had resolved never to forget that beneath everything was a patient—an individual. In his own training Seddons had seen the cocoon of personal isolation—a safeguard against close contact with individual patients—grow around others. Sometimes it was a defensive measure, a deliberate insulation of personal emotions and personal involvement. He felt strong enough himself, though, to get along without the insulation. Moreover, to make sure it did not grow, he forced himself sometimes to think and soliloquize as he was doing now. Perhaps it would surprise some of his friends who thought of Mike Seddons only as a buoyant extrovert to know some of the thoughts that went on inside him. Perhaps it wouldn’t, though; the mind, brain—or whatever you called it—was an unpredictable machine.

What of McNeil? Did he feel anything, or was there a shell around the pathology resident too? Seddons did not know, but he suspected there was. And Pearson? He had no doubts there. Joe Pearson was cold and clinical all the way through. Despite his showmanship the years of pathology had chilled him. Seddons looked at the old man. He had removed the heart from the body and was scrutinizing it carefully. Now he turned to the student nurses.

“The medical history of this man shows that three years ago he suffered a first coronary attack and then a second attack earlier this week. So first we’ll examine the coronary arteries.” As the nurses watched intently Pearson delicately opened the heart-muscle arteries.

“Somewhere here we should discover the area of thrombosis . . . yes, there it is.” He pointed with the tip of a metal probe. In the main branch of the left coronary artery, an inch beyond its origin, he had exposed a pale, half-inch clot. He held it out for the girls to see.

“Now we’ll examine the heart itself.” Pearson laid the organ on a dissecting board and sliced down the center with a knife. He turned the two sections side by side, peered at them, then beckoned the nurses closer. Hesitantly they moved in.

“Do you notice this area of scarring in the muscle?” Pearson indicated some streaks of white fibrous tissue in the heart, and the nurses craned over the gaping red body cavity to see more closely. “There’s the evidence of the coronary attack three years ago—an old infarct which has healed.”

Pearson paused, then went on. “We have the signs of the latest attack here in the left ventricle. Notice the central area of pallor surrounded by a zone of hemorrhage.” He pointed to a small dark-red stain with a light center, contrasting with the red-brown texture of the rest of the heart muscle.

Pearson turned to the surgical resident. “Would you agree with me, Dr. Seddons, that the diagnosis of death by coronary thrombosis seems fairly well established?”

“Yes, I would,” Seddons answered politely. No doubt about it, he thought. A tiny blood clot, not much thicker than a piece of spaghetti; that was all it took to cut you off for good. He watched the older pathologist put the heart aside.

Vivian was steadier now. She believed she had herself in hand. Near the beginning, and when the saw had cut into the dead man’s skull, she had felt the blood drain from her head, her senses swim. She knew then she had been close to fainting and had determined not to. For no reason she had suddenly remembered an incident in her childhood. On a holiday, deep in the Oregon forest, her father had fallen on an open hunting knife and cut his leg badly. Surprisingly in so strong a man, he had quailed at the sight of so much of his own blood, and her mother, usually more at home in the drawing room than the woods, had become suddenly strong. She had fashioned a tourniquet, stemmed the blood, and sent Vivian running for help. Then, with Vivian’s father being carried through the woods on an improvised litter of branches, every half-hour she had released the tourniquet to keep circulation going, then tightened it to halt the bleeding again. Afterward the doctors had said she had saved the leg from amputation. Vivian had long since forgotten the incident, but remembering it now had given her strength. After that she knew there would not be any problem about watching an autopsy again.

“Any questions?” It was Dr. Pearson asking.

Vivian had one. “The organs—those that you take out of the body. What happens to them, please?”

“We shall keep them, probably for a week. That is—the heart, lungs, stomach, kidneys, liver, pancreas, spleen, and brain. Then we shall make a gross examination which will be recorded in detail. At that time also we’ll be studying organs removed at other autopsies—probably six to a dozen cases all together.”

It sounded so cold and impersonal, Vivian thought. But maybe you had to get that way if you did this all the time. Involuntarily she shuddered. Mike Seddons caught her eye and smiled slightly. She wondered if he was amused or being sympathetic. She could not be sure. Now one of the other girls, was putting a question. She sounded uneasy, almost afraid to ask. “The body—is it buried then . . . just by itself?”

This was an old one. Pearson answered it. “It varies. Teaching centers such as this usually do more study after autopsies than is done in non-teaching hospitals. In this hospital just the shell of the body goes on to the undertakers.” He added as an afterthought: “They wouldn’t thank us for putting the organs back anyway. Just be a nuisance when they’re embalming.”

That was true, McNeil reflected. Maybe not the gentlest way of putting it, but true all the same. He had sometimes wondered himself if mourners and others who visited funeral parlors knew how little remained in a body that had been autopsied. After an autopsy like this one, and depending on how busy a pathology department was, it might be weeks before the body organs were disposed of finally, and even then small specimens from each were kept stored indefinitely.

“Are there never any exceptions?” The student nurse asking the questions seemed persistent. Pearson did not appear to object though. Maybe this is one of his patient days, McNeil thought. The old man had them occasionally.

“Yes, there are,” he was saying. “Before we can do any autopsy we must have permission from the family of the deceased. Sometimes that permission is unrestricted, as in this case, and then we can examine the entire head and torso. At other times we may get only limited permission. For example, a family may ask specifically that the cranial contents be undisturbed. When that happens in this hospital we respect those wishes.”

“Thank you, Doctor.” Apparently the girl was satisfied, whatever her reason had been for asking.

But Pearson had not finished.

“You do run into cases where for reasons of religious faith the organs are required for burial with the body. In that case, of course, we comply with the request.”

“How about Catholics?” It was one of the other girls this time. “Do they insist on that?”

“Most of them don’t, but there are some Catholic hospitals which do. That makes the pathologist’s work difficult. Usually.”

As he added the last word Pearson glanced sardonically at McNeil. Both of them knew what Pearson was thinking—one of the larger Catholic hospitals across town had a standing order that the organs of all bodies autopsied were to be returned to the body for burial. But sometimes a little sleight of hand was practiced. The busy pathology department of the other hospital frequently kept a spare set of organs on hand. Thus, when a new autopsy was done, the organs removed were replaced by the spare ones, so that the body could be released and the latest set of organs examined at leisure. These organs, in turn, were then used for the next body. Thus the pathologists were, in effect, always one ahead of the game.

McNeil knew that Pearson, though not a Catholic, disapproved of this. And whatever else you might say about the old man, he always insisted on following autopsy permissions both to the letter and the spirit. There was one phrase, sometimes used in completing the official form, which read “limited to abdominal incision.” Some pathologists he knew did a full autopsy with this single incision. As he had heard one man put it, “With an abdominal incision, if you’ve a mind to, you can reach up inside and get everything, including the tongue.” Pearson—to his credit, McNeil thought—would never permit this, and in Three Counties an “abdominal incision” release meant examination of the abdomen only.

Pearson had turned his attention back to the body.

“We’ll go on now to examine . . .” Pearson stopped and peered down. He reached for a knife and probed gingerly. Then he let out a grunt of interest.

“McNeil, Seddons, take a look at this.”

Pearson moved aside, and the pathology resident leaned over the area that Pearson had been studying. He nodded. The pleura, normally a transparent, glistening membrane covering the lungs, had a thick coating of scarring—a dense, white fibrous tissue. It was a signal of tuberculosis; whether old or recent they would know in a moment. He moved aside for Seddons.

“Palpate the lungs, Seddons.” It was Pearson. “I imagine you’ll find some evidence there.”

The surgical resident grasped the lungs, probing with his fingers. The cavities beneath the surface were detectable at once. He looked up at Pearson and nodded. McNeil had turned to the case-history papers. He used a clean knife to lift the pages so he would not stain them.

“Was there a chest X-ray on admission?” Pearson asked.

The resident shook his head. “The patient was in shock. There’s a note here it wasn’t done.”

“We’ll take a vertical slice to see what’s visible.” Pearson was talking to the nurses again as he moved back to the table. He removed the lungs and cut smoothly down the center of one. It was there unmistakably—fibrocaseous tuberculosis, well advanced. The lung had a honeycombed appearance, like ping-pong balls fastened together, then cut through the center—a festering, evil growth that only the heart had beaten to the kill.

“Can you see it?”

Seddons answered Pearson’s question. “Yes. Looks like it was a tossup whether this or the heart would get him first.”

“It’s always a tossup what we die of.” Pearson looked across at the nurses. “This man had advanced tuberculosis. As Dr. Seddons observed, it would have killed him very soon. Presumably neither he nor his physician were aware of its presence.”

Now Pearson peeled off his gloves and began to remove his gown. The performance is over, Seddons thought. The bit players and stagehands will do the cleaning up. McNeil and the resident would put the essential organs into a pail and label it with the case number. The remainder would be put back into the body, with linen waste added if necessary to fill the cavities out. Then they would stitch up roughly, using a big baseball stitch—over and under—because the area they had been working on would be covered decorously with clothing in the coffin; and when they had finished the body would go in refrigeration to await the undertaker.

Pearson had put on the white lab coat with which he entered the autopsy room and was lighting a new cigar. It was a characteristic that he left behind him through the hospital a trail of half-smoked cigar butts, usually for someone else to deposit in an ash tray. He addressed himself to the nurses.

“There will be times in your careers,” he said, “when you will have patients die. It will be necessary then to obtain permission for an autopsy from the next of kin. Sometimes this will fall to the physician, sometimes to you. When that happens you will occasionally meet resistance. It is hard for any person to sanction—even after death—the mutilation of someone they have loved. This is understandable.”

Pearson paused. For a moment Seddons found himself having second thoughts about the old man. Was there some warmth, some humanity, in him after all?

“When you need to muster arguments,” Pearson said, “to convince some individual of the need for autopsy, I hope you will remember what you have seen today and use it as an example.”

He had his cigar going now and waved it at the table. “This man has been tuberculous for many months. It is possible he may have infected others around him—his family, people he worked with, even some in this hospital. If there had been no autopsy, some of these people might have developed tuberculosis and it could have remained undetected, as it did here, until too late.”

Two of the student nurses moved back instinctively from the table.

Pearson shook his head. “Within reason there is no danger of infection here. Tuberculosis is a respiratory disease. But because of what we have learned today, those who have been close to this man will be kept under observation and given periodic checks for several years to come.”

To his own surprise Seddons found himself stirred by Pearson’s words. He makes it sound good, he thought; what’s more, he believes in what he is saying. He discovered that at this moment he was liking the old man.

As if he had read Seddons’ mind, Pearson looked over to the surgical resident. With a mocking smile: “Pathology has its victories too, Dr. Seddons.”

He nodded at the nurses. Then he was gone, leaving a cloud of cigar smoke behind.

Four

The monthly surgical-mortality conference was scheduled for 2:30 p.m. At three minutes to the half-hour Dr. Lucy Grainger, a little harried as if time were working against her, hurried into the administration reception office. “Am I late?” she asked the secretary at the information desk.

“I don’t think they’ve started, Dr. Grainger. They just went in the board room.” The girl had indicated the double oak-paneled doorway down the hall, and now, as she approached, Lucy could hear a hum of conversation from inside.

As she entered the big room with its pile carpet, long walnut table, and carved chairs, she found herself close to Kent O’Donnell and another younger man she did not recognize. Around them was a babel of talk and the air was thick with tobacco smoke. The monthly mortality conferences were usually looked on as command performances, and already most of the hospital’s forty-odd staff surgeons had arrived, as well as house staff—interns and residents.

Date: 2014-12-21; view: 730