Selected Poetry: 1974-
IN THE SHADOW OF THE CATHEDRAL
As an intern, Jack Fleming had become aware that there was a laboratory on Angell Center. Fleeting glimpses of the area, afforded him when he had been called to Corridor O to restart IVs, or attempt the resolution of incipient disasters, supported his growing appreciation of a sense of intimacy surrounding the oncology service.
Now, as an oncology fellow, the lab was an integral part of Dr. Fleming’s base of operations. His day usually began there. The medical students, interns, and residents rotating through the oncology service traditionally met with the fellows in the lab each morning before rounds. In the evenings, after he had completed his diagnostic procedures, evaluated his new admissions, reviewed his patients' laboratory reports, and examined those patients who where critically ill, Dr. Fleming would spend any available time seated like a monk at illuminations before Dr. Michailovich’s teaching microscope. The instrument was equipped with double binocular objectives and was housed in the lab to make it accessible to anyone wishing to make use of it.
Fleming would sit with the patience of an anchorite poring over stained glass slides made of cover slipped cancers cloistered in paraffin prisons. Each slide represented a point along the vast curving sweep of information that extends as a march of photons from the frozen section. Secrets hidden within the torn, sutured flesh of the biopsied patient pass through the intercession of the complex optical systems of the microscope, and then on to the ganglion fields of the physician’s integrating cerebration.
At times Dr. Michailovich would join him. Together, they would scan Technicolor depictions of malignant diseases. At such times, jealously coveted by all of the fellows, communication between professor and student would achieve an organic level of autonomous existence. At times the communication would become unspoken, yet pure at the level of the eyes. Dr. Fleming and his chief would crouch hunched over like ancient priests, staring at one another across the stage of the microscope, engrossed in the intimate ritual of teaching.
Jack Fleming sat back in a chair with his feet propped on Maurice Dubois’ desk. Dr. Fleming was scanning an article on the neurological complications of malignant diseases in Cancer—the monthly journal of the American Cancer Society. He was awaiting the arrival of Dr. Dubois, his rounding partner for the weekend.
The north end of the lab, where Dr. Fleming was sitting, had been converted into a small lounge for the oncology service staff. Birthday and farewell parties were celebrated here, usually with a Sander’s yellow layer cake with butter cream frosting and crushed walnuts. Served eucharistically, using tongue blades as universal eating utensils, the cake was accompanied by copious draughts of coffee, poured steaming hot into the one essential item of equipage on Angell Center—one’s own clearly identifiable chalice.
Dr. Dubois, who was Director of Research Activities for the center was also headquartered at the lab’s north end. From his desk, which was cluttered with research protocols, Maurice Dubois supervised the Angell Center research projects currently in progress.
From his vantage point at Maurice Dubois’ desk, Dr. Fleming surveyed the lab as it extended southward. The space before him was a 1200 square foot microcosm, with armies of reagent bottles standing on row after row of black slate shelving.
During the week, the hum of activity and the utilization of every conceivable inch of available space reminded Fleming of Bruegel’s etching of the chamber of an alchemist. Rubber hosing attached to massive bottles of distilled water snaked toward small sinks encased in the surfaces of the working areas. Graduated cylinders stood in ranks or—inverted upon drying pegs—dangled precariously at incongruous angles.
When the lab was busy, one could hear the sound of Bunsen burners hissing. Strange, fuming solutions seethed or steamed in beakers sitting upon tripods. Background tapes played the soft refrains of classical music of Medieval or Elizabethan vein. These lilting notes might be interrupted at times by the distant sound of a glass implosion, as the crystal splinters of a vacuum tube collided with the floor.
Against the south wall of the room stood a chemical hood, its glass walls encasing a whistling draft. This device was used to fire small caldrons of malodorous substances and protected the technicians from noxious emissions. A large centrifuge, able to separate the components of the blood in seconds, stood bulkily in a corner adjacent to the hood. Hourglasses, clocks for timing reactions, flagons and pots, mortars and pestles, tongs, bellows, and books of instruction lay scattered about in a disordered array.
A long desktop table was attached to the west wall. Glass paned cabinets mounted above the table were pregnant with books and Kodachrome cassettes. The cassettes were filled with photomicrographs of pathological specimens and photographs of the sick collected during Dr. Michailovich’s long years of practice.
Four binocular AO microscopes, with electric light sources and mechanical stages, sat rigidly erect upon the desktop table like the celebrants of a High Mass. Corresponding to the exact position of each scope, a stool lay hidden beneath the desktop. A sink, used for the staining of blood, urine sediment, bone marrow, or bacteria trapped in pearls of phlegm, stood along the west aisle. The gleaming porcelain surface of the sink was spattered with the stains of deep blue hematoxylin dye and the red oranges of eosin and mordant iodine.
Within the anachronistic milieu of the Angell Center lab, during the week, a technician might be found sitting askance upon a high footstool, peering languidly into a beaker of fluid which she stirs with a glass rod.
With this last image imprinted upon his mind, Jack Fleming rose from his chair, casually tossing the medical journal aside. He sauntered past a row of autoclaves mounted into the east wall of the lab, fingered the gleaming stainless steel spokes of each of three massive handles, and entered a small darkroom, where the coffee machine was located. In the established division of labor on the oncology service, the fellow was responsible for priming the machine on weekends. A rich smell of coffee permeated the small room like the pervading aroma of a swinging censer. Fleming poured himself a cup and stood in the semi-darkness, studying a series of markings on the wall that reminded him of the ancient, untranslatable runes of some lost religion. He had been meaning to inquire about the significance of these.
In the months to come, this darkened room would become a sanctuary for Fleming. He would use it as a place to regroup from the stresses of his work. The darkness and the barely audible refrains of the music would wash over him there, soothing his uneasiness and his anguish.
Fleming emerged from the darkroom when he heard Maurice Dubois enter the lab.
"Hey, hey, Jackson, my man, ready to make some rounds?"
Energy emanated from Maurice Dubois like a force field. He had been the third full-time member to join the Angell Center faculty. He had been recruited because he held a PhD in biochemistry, in addition to his M.D. degree. His background in the basic sciences supported his present position of Director of Research Activities.
"I see you made it to work before me this morning, Jackson," said Dr. Dubois, as he eased past his younger colleague and entered the darkroom.
Fleming smiled as Maurice poured coffee into the cup he had retrieved from a rack of wooden pegs above the sink. No one ever arrived at or left work before Maurice Dubois. Big Mike Morgagni had first pointed out to Fleming that no matter how late in the evening an order or note was written on one of his patients, Dr. Dubois managed to leave another at least fifteen minutes later. The fellows were intent upon catching Maurice leaving early some evening so they could pimp him about it, but that never happened. Fleming knew that Dr. Dubois had probably seen two or three patients already.
Dr. Dubois was a youthful appearing black man in his late thirties. His features were finely chiseled. He was balding slightly and he wore a pair of spectacles with semi-lunar shaped lenses that rode low on his nose. His intensely sensitive eyes bobbed and weaved above them. Dr. Dubois’ long-fingered, smoothly contoured hands were never still. He used them with exceptional technical skill when touching patients. Maurice seemed to embrace his world with a finely articulated caress.
Maurice Dubois bore the burdens of his race as a cross, but bore them with the stately nobility of a magus. His stated goal was to become the greatest oncologist in the world. His patients adored him. He idolized Dr. Michailovich and lovingly referred to the professor as "the book."
Jack Fleming and Maurice Dubois finished their coffee. Fleming yawned tremulously, as he tried to shake off his sleepiness.
"So, Jackson," said Dr. Dubois, rinsing his cup in the darkroom sink, "let’s go see some patients."
The two physicians left the lab through the door in the east wall that led to the patient waiting area for Angell Center, the outpatient facility of the oncology service. The waiting room was small, with seating limited to eight chairs for patients. The area also housed the desk of the receptionist, Liz Pynchon. A large bank of filling cabinets filled with medical records further encroached upon the available space.
A short hallway connected the Angell Center waiting room to Corridor O, the original inpatient ward for the oncology service. Like small chapels extending from an apse, a series of smaller spaces cascaded from this hallway, including several examination rooms, a minor surgical suite, a drug preparation cubicle, and the offices of Dr. Michailovich and that of the Associate Director of the oncology service, Dr. Francis Heller. Dr. Heller had been Semyon Michailovich’s first oncology fellow.
Drs. Fleming and Dubois stopped first at a large bulletin board, where they updated the oncology service’s patient list, which had been prepared by Liz Pynchon the day before. Fleming, who had drawn the Friday-Sunday nights on call, penned in the names, hospital numbers, and locations of the three patients who had been admitted to the service on Friday, September 20, 1968. He also drew a line through the data on 16 year-old Matthew O’Brian, 48639.
Although the amount of work that had to be completed on the weekends sometimes kept the two rounders in the hospital until the early hours of the evening, Fleming had been gratified to find night coverage of the service from home relatively easy. He was rarely called back to the hospital and he was able to sleep. Internship and residency calls had been much more rigorous. The last entry on a house physician’s list of chores always seemed to recede like the surface of the water for Tantalus in Hell. Fleming could recall the many times he had stood in the breakfast line, dead tired after a challenging call, feeling like some kind of reverse alchemy had turned all of the gold in his body into lead. This morning, he was relatively sharp and ready to go.
The list now contained 39 names. Fleming and Dubois would divide the patients between them. Fleming would round on the 18 patients on Corridor O, while Maurice Dubois covered the "off-service" patients scattered throughout the rest of the hospital. The staff euphemistically referred to these patients as the "metastases."
The main corridor of the hospital’s second floor extended like an enormous nave to an eastern terminus that comprised the transept connecting Angell Center with Corridor O. The entire eastern extremity occupied by the oncology service seemed to have been added to the main plan as an afterthought. The architectural history that might have shed light on this strange conglomeration of space was lost somewhere in a musty archive.
As Jack Fleming arrived at the Corridor O nursing station, Michele Kelly, R.N., the night shift nurse was occupied somewhere on the ward. Fleming began to pull charts, loading these into the portable record rack he would take with him on rounds.
Old Harold was strapped to his wheelchair a few feet away, out of his room for his morning constitutional. The old man’s "exercise" had to be completed before visiting hours, because Old Harold had a tendency to pester people. He sat in his chair like a burlap bag of rotting produce, drooling and lolling his head like a hydrocephalic doll in a carnival sideshow. He began to signal to Fleming with the urgency of an epileptic on a high wire who fears he may convulse at any second.
Old Harold had been a truck farmer. His body was now so ridden with cancer that there were only a few islands of normal tissue remaining. Old Harold was a problem case. Nobody wanted him. His family could have cared less how or when or if he died. The nursing home, from where he had been recently transferred, became concerned when Old Harold had reached that state of being when one engages reality only in snatches, of time and of people.
Old Harold had no conception of night or day. He lived in a perhaps enviable world where he made all of the rules. He seemed at times like some mad engineer squealing with delight as all of his cars flew off the tracks. Old Harold was a master of inhuman shrieks. These he directed without warning and with blood thirsty cunning at the unwary. He was sedated to within the limits of propriety without effect, other than to feed new and strange visions to his dreams.
Mr. Harold Courtnay, aged 73, had been admitted to Corridor O for reassessment of his case. He was a potential candidate for investigational chemotherapy. He had bronchogenic carcinoma of the lung with widespread metastases. The frontal lobes of Old Harold’s brain had been replaced by masses of malignant tissue that had now eroded his skull from within. Old Harold resembled an alien intelligence from a science fiction film at those times when he was able to hold his head up long enough to strike the appropriate pose.
The urgency of Old Harold’s importuning and the possibility of some obnoxious retaliation should he not respond, prompted Fleming to approach the tiny arena where Old Harold held court. Grasping Fleming’s coat, the old man lifted himself toward the oncologist’s ear and began a strange monologue. Speaking softly at first, Old Harold’s voice rose to a strident pitch. He spewed forth an incomprehensible diatribe containing recognizable signposts at intervals—blood from his lungs, surgery, and burning.
Old Harold frantically tugged at Fleming’s hand, placing it beneath his besmeared and spattered robe. He began to slowly draw Fleming’s fingers over the irradiation fields of his chest, which was studded with ominous nodules growing like diabolical flowers in the wasteland of his skin. Old Harold’s eyes were feverish, betraying anxiety and turmoil, as they searched Fleming's face for understanding. The eyes seemed to flicker tragically with the last vestiges of lucidity that remained in the twilight of Old Harold’s life. The old man burst into tears and then fell back into the wheelchair, drawing his arms and shoulders into his chest, his body wracked by several convulsive sobs.
"Trying to cop a free feel off Old Harold?" asked nurse Kelly, who had approached unnoticed and was standing there leering at Fleming bemusedly. "Dr. Fleming, you should be ashamed."
"Got anything better, Michele?" Fleming retorted, as he straightened his white coat and returned to the task of filling the portable chart rack.
Michele Kelly looked at him intently. Then, without uttering a sound, she mimed an exaggerated but silent, "Fuck you!"
Fleming smiled as he continued to arrange his charts in methodical numerical order.
"Say 99, again…again…99…again."
Fleming, wearing a green paper mask that covered his nose and mouth, plastic gloves, and a disposable green paper gown strained to appreciate subtle differences in the vibrations discernible on the skin overlying Ira Goldstein’s posterior chest, as the latter croaked the incantations, "99, 99, 99."
The vibrations established in Mr. Goldstein’s larynx by his chanting should have been transmitted symmetrically and with uniform intensity to comparable sectors of skin overlying the patient’s right and left lungs. Fleming detected subtle accentuation of tactile fremitus in the right posterior hemithorax. Pneumonia was the most likely explanation.
Fleming next placed his left middle finger firmly into the interspaces between Mr. Goldstein’s ribs. With a sharp flick of his right wrist, Fleming percussed the patient’s chest, striking his own immobile finger with its counterpart on his opposite hand. Plexor struck pleximeter, an ancient ritual. Instead of the resonant tone of normally aerated lung, Fleming could appreciate unmistakable dullness in the same suspect area of Ira Goldstein’s chest.
The technique Fleming was using had been promulgated by Leopold Auenbrugger von Auenbrugg in a treatise on percussion published in 1761. Auenbrugger had based his discovery on the remembrance of things past. As a small boy, Auenbrugger had used the technique to determine the volume of wine remaining in casks in his father’s Inn. He had extrapolated the method to the detection of fluid in the lungs of the sick at the Spanish Military Hospital at Vienna.
"Now, open your mouth and breathe…again…again. In and out, like this. Breathe a little deeper. That’s it. That’s better."
Fleming listened to the sounds of breathing through the intercession of the small tubes of the stethoscope that had connected his existence to that of Ira Goldstein in Room 289. As he listened, Fleming recalled that Rene Theophile Hyacinthe Laennec had invented the stethoscope while working at the Hopital Neckar in Paris to avoid the discomfiture of direct contact of his ear with a patient’s chest. Had he been a practitioner of the healing arts in the era before Laennec, Fleming could image a young consumptive holding his head gently to her breast, allowing him to listen impotently to the crepitant destruction of her tuberculous lungs. Through his stethoscope, Fleming heard the whistling sounds of consolidation in Ira Goldstein’s chest.
Ira Goldstein considered his cancer of the rectum a visitation from God akin to Tevye’s poverty in Fiddler on the Roof. Mr. Goldstein owned a small haberdashery. He frequently brought small gifts of undershorts and socks to his physicians. Perhaps he felt that such bargaining with God might do him some good. Although he could intellectually accept the fate that God had sent him, as he had done all of his life, who could blame him for trying to advance his case a little with good works?
The treatment of Mr. Goldstein’s malignant disease with irradiation and chemotherapy had ravished his bone marrow, destroying the majority of his white blood cells. He had been deprived of the tiny guardians of sterility that might have swept the invaders from his lungs and bloodstream like hoards of ravenous shrews. Because of severe leukopenia, Mr. Goldstein had been admitted to an isolation room on Corridor O.
Despite the precautions taken to protect him from infection, Mr. Goldstein had spiked a temperature elevation to 103° at 6:00 A.M. that morning. Michele Kelly had notified the intern on call, who had ordered a blood culture and who had instructed the nurse to monitor the patient’s vital signs. The intern had then gone back to sleep without bothering to come down to Corridor O to see the patient. Such inaction represented a slight mistake in judgement. Fleming noted the intern’s name from the verbal order Kelly had taken. A slight ass chewing would happen later that morning.
Fleming concluded that Ira Goldstein had pneumonia with probable septicemia. After carefully explaining the situation to the patient, he arranged for a portable chest X-ray and wrote orders for additional antibiotics. Fortunately, Mr. Goldstein was not in shock.
Jack Fleming recalled the first time he had made a diagnosis of pneumonia on Corridor O. He had been the intern on call to the service one night and had responded to evaluate a similar patient with a fever spike. The signs of consolidation in the patient’s chest had seemed unmistakable. Fleming had written what he felt had been an impressive note describing his findings. He had initiated therapy with penicillin.
When he learned that Dr. Michailovich had asked to see him the next afternoon, Fleming had assumed that the visit was to offer congratulations for such a job well done. He had been mortified instead to learn that he had blown the whole case. The signs of consolidation he had heard were due to a massive fluid accumulation in the patient’s chest. The patient had not had pneumonia at all. Fleming had made a devastating and glaring error.
The memorable aspect of this potentially degrading experience had been the fact that Dr. Michailovich had turned the episode into the most significant educational encounter of Fleming’s career to that point.
First, Dr. Michailovich had explained the subtle differences between the physical signs produced by fluid in the pleural space compared with the signs caused by pneumonia. The oncology professor’s discussion had been the most lucid exposition of the subtleties of clinical medicine Fleming had ever heard.
Then, Dr. Michailovich had taken Fleming to the bedsides of two patients fortuitously in the hospital at that time. Each of the patients demonstrated one of the two conditions in question. Fleming had been able to appreciate the signs produced by each of the abnormal conditions. Dr. Michailovich’s command of the techniques of physical diagnosis had been the most impressive Fleming had ever seen. His hands had played over the body of each patient like those of a concert pianist touching lightly upon the keys of his instrument. His immense love of teaching had been obvious. Themes had cascaded from him in epicycles of didactic precision. No one at Fleming’s medical school had ever come close to such a virtuoso performance.
Jack Fleming had continued his close observation of the oncology service throughout his internship year. He never missed one of Dr. Michailovich’s teaching conferences. During his medical residency, Fleming did two elective rotations on Corridor O. As Fleming continued to observe Dr. Michailovich’s incredible capacities as physician and teacher, a desire to emulate him in every way quickly materialized. Fleming would join grand rounds with the oncology service staff whenever he was free.
During the fall of his second year of medical residency, Fleming made an appointment to talk to Dr. Michailovich.
"Sir," he had begun that day, "I was wondering if I could talk to you about a job for next year."
Jack Fleming had been awarded one of four fellowships in clinical oncology for the 1968/69 academic year.
Dr. Fleming left the portable chart rack in the hall. He entered Room 290, carrying the medical records of the two patients with him. Fleming had read the nurse’s notes. The patients in 290 had not had a good night.
The patient in Bed 2 was a 46 year-old woman named Karen McCaffrey. She was a patient of Francis Heller. He illness had begun around Christmas in 1966. She had noticed that her clothing was fitting more tightly and that she had inexplicably gained a great deal of weight, far out of proportion to her modest increase in caloric intake over the holidays. Assiduous dieting had not improved the situation.
Shortly after the first of the year, Mrs. McCaffrey and her husband had become concerned about the possibility that she might be pregnant and this had prompted her to see her personal physician. Karen McCaffrey was not pregnant. At the time of an exploratory laparotomy, she was found to have a far advanced ovarian malignancy. The swelling and weight gain had been due to the accumulation of fluid within her abdomen.
The disease was inoperable. Mrs. McCaffrey had received strip irradiation to the abdomen and pelvis with Cobalt 60. Her initial treatment had controlled the fluid accumulation until August, 1967, when the fluid reappeared. This time, however, the fluid accumulation was accompanied by intestinal obstruction due to encasement of the bowel by cancerous implants, so called abdominal carcinomatosis. Control of the obstruction required continuous suction effected by the placement of a decompression tube through the patient’s nose.
At that point, Mrs. McCaffrey had been referred to the oncology service. Chemotherapy with the drug chlorambucil had been initiated. Karen McCaffrey had responded dramatically. She had been discharged home in complete remission in October.
The initial remission had lasted five and a half months, but subsequent events had not been so encouraging. The disease had recurred in March, 1968. Since that time, Mrs. McCaffrey had been readmitted to the hospital on eight occasions with recurrent partial intestinal obstruction and with re-accumulation of abdominal fluid. In each instance, drainage of the fluid, reinsertion of the intestinal tube, and additional chemotherapy, more recently with investigational drugs, had resulted in sufficient improvement to allow Mrs. McCaffrey to go home for several days or a week or two at a time.
Frank McCaffrey, the patient’s husband, had insisted that Dr. Heller continue to fight for his wife as long as there was any conceivable chance of a response.
During her last admission, Karen McCaffrey had become temporarily psychotic. She had slashed her wrists with the broken end of a thermometer left in her room by one of the aides. This unusual reaction had been attributed to a heretofore unrecognized toxic effect on the nervous system of mitogillin (NSC-69529), the most recent chemotherapeutic agent used in the treatment of Mrs. McCaffrey’s disease.
Despite the unusual toxicity, mitogillin had produced a brief remission. Unfortunately, Mrs. McCaffrey had been readmitted to the hospital the preceding Thursday.
Fleming approached Mrs. McCaffrey’s bedside. The night lamp cast an eerie interplay of highlights and shadows upon the form lying very still in the bed. Fleming thought she might be asleep. The pinched profile of the patient’s head stood out like that of an Egyptian mummy. The scalp bore only stringy traces of Mrs. McCaffrey’s auburn hair. An ivory tube emerged from the patient’s scabbed and crusted right nostril and then snaked its way to the Gomco suction machine at the bedside. A small red light on the machine glowed intermittently in the semidarkness, indicating that the apparatus was drawing off intestinal secretions periodically.
The patient’s arms were like sticks. The right arm was heavily bandaged at the elbow, where a minor surgical procedure had been necessary in order to isolate an accessible vein. The thinness of Karen McCaffrey’s arms and neck contrasted unreasonably with the massive enlargement of her abdomen, which protruded grotesquely from beneath the sheets. Mrs. McCaffrey appeared to be in the terminal stages of some strange, unwanted pregnancy. Fleming could appreciate the slow, rhythmic rise and fall of Karen McCaffrey’s chest.
"Mrs. McCaffrey," he whispered, "are you awake?"
"Frank? Is that you?"
"It’s Dr. Fleming, Mrs. McCaffrey. I’m making rounds this morning for Dr. Heller."
Karen McCaffrey’s only response was to turn her head away from Fleming in the direction of the wall.
Fleming held her right hand in his. He mechanically checked the intravenous infusion and the nasogastric suction apparatus.
"Is there anything I can get for you this morning?" Fleming asked.
Mrs. McCaffrey squeezed Fleming’s hand. She made a feeble effort to lift her body toward him. Failing, she collapsed back into the bed. She turned her head slowly in his direction and his eyes met hers. Fleming peered into two hollow pools of infinite sadness.
"Please let me go home, Frank," she said to him. "I’m so tired. I just want to go home."
"It’s alright, Mrs. McCaffrey," Fleming said, grasping the patient’s hand more firmly in both of his own. "The new medicine will be started on Monday. You’ll be home before you know it."
Fleming released Karen McCaffrey’s hand and turned to continue his rounds. She had turned her head away from him again. Her left hand was groping blindly for the rosary on her bedside stand.
Directing his attention to the younger woman in Bed 1, Fleming noticed that she was pointing intently toward the door. Evidently, she wished to speak to him outside in the hall.
"Look, Doc," she said heatedly, "you have got to get me transferred out of here. I never should have been admitted to a ward like this, with all of these cancer patients all over the place. I swear, I know that woman in there is going to die today."
Loretta Pottersfeld was 20 years old. She was a junior at a small Catholic University situated near the center of the city. Loretta was majoring in comparative religion. Four months earlier, she had developed insidious fatigue. Attributing the symptom to the stresses of college life, Loretta had ignored her condition at first. Finally, she had consulted a physician at her school’s student health service. She was found to have an enlarged spleen and several abnormal blood counts. Further testing revealed that Loretta had chronic myelogenous leukemia, an unusual diagnosis in a female of her age.
According to her mother, Loretta had exhibited psychic ability throughout her life. She had become morbidly convinced that she would die one day of leukemia. Her parents had insisted in no uncertain terms, therefore, that Loretta not be informed of the diagnosis.
The policy on the oncology service in this regard dictated that no patient was ever to be lied to in response to direct questioning about any aspect of his or her disease. Loretta Pottersfeld had never asked for specifics. She seemed content with the idea that she had a chronic disease of the blood that had a good long-term prognosis. She had been told that her condition could be controlled with medication and occasional blood transfusions.
In recent weeks, however, Loretta Pottersfeld had developed increasing numbers of highly malignant blast forms among the white blood cells on her blood smear. These changes implied that her disease was entering a terminal phase. In view of the poor prognosis, the family had concurred with Dr. Michailovich’s recommendation to admit Loretta for another bone marrow aspiration to confirm the blast crisis, and then to treat her with a new anti-leukemic drug called cytosine arabinoside.
"I’ll admit that Mrs. McCaffrey is quite ill," Fleming responded, "but we have no reason to feel that her illness is terminal at this point, Miss Pottersfeld."
Fleming did believe Mrs. McCaffrey had an excellent chance of achieving another remission. Her disease was confined, after all, to the abdomen and had not spread widely.
"I know this sounds crazy," Loretta Pottersfeld insisted, "but I get a feeling about these things sometimes. I tell you she’s going to die today! She kept us both up all night talking about it. She sees these dead people, relatives mostly, right there in that room. I just know it is going to happen. I mean I couldn’t feel more sorry for anybody in the world than that dear lady in there, but I’ve never seen anything like this before. I don’t want to have to witness someone I know dying right before my eyes. Now, I’m telling you I want to be transferred out of here!"
Fleming tried to reassure Miss Pottersfeld to no avail. He finally agreed to discuss her situation with Dr. Michailovich as soon as he finished rounds. His only hesitation to effecting an immediate transfer lay in his knowledge that it was prudent to keep patients who were candidates for investigational drugs on Corridor O whenever possible. The nursing staff on the unit was more experienced in the administration of the drugs and was more capable of dealing with toxic reactions.
Fleming stared down at Loretta Pottersfeld as he prepared to leave. He thought for an instant that he could visualize the hoards of tiny myeloblasts, deadly far out of proportion to their diminutive size, that were mobilizing in the perivascular spaces of her liver, spleen, bone marrow, and brain in preparation for a ruthless and final assault upon her young life. Fleming shook off the vision and turned away.
Fleming passed the Corridor O nursing station on his left as he proceeded in the direction of Room 291. Like a group of novices at matins, the student nurses had gathered in the station, taking morning report with the LPNs. Sister Kelly, who seemed to Fleming a most seductive Mother Superior, was softly reading treatment plans from a Cardex, her voice a melodious incantation.
Fleming thought it best not to interrupt Kelly’s discourse with Loretta Pottersfeld's request for transfer. He did hand Mr. Goldstein’s chart to one of the LPNs. As he did so, Fleming noticed that two of the students were dressed in habit, having abjured for a time the cloistered walks of some convent for the world of the flesh on Corridor O.
As he approached Room 291, Fleming passed a service elevator on his right. For many, an unscheduled journey in this rickety cage marked the end of the line, the conclusion in victory of their disease’s turbulent reign.
The two male patients in 291 presented no significant problems. Charles Stuart, the eldest, in Bed 1, was post-operative. His case was being more actively followed by the surgical service. Charlie Stuart was a prince of a guy, the kind who would literally cut his head off for a friend. He had developed a sore on his left foot a few weeks before his admission. Being attuned to the "Seven Danger Signals," he had consulted his physician. An excisional biopsy had been done.
Pathologically, the lesion was a bizarre conglomeration of highly distorted cells, twisting and writhing across the high powered fields of the microscope like a parade of the convulsing victims of a brain fever. The arrangement of the malignant cells was misshapen and grotesque, as if the tumor were exploding from within. Upon review of the path slides, Dr. Michailovich agreed that the specimen was consistent with a highly anaplastic malignant melanoma.
Because of the aggressive appearance of Mr. Stuart’s neoplasm, the possibility was highly likely that small nests of cells, microscopic in size, had already invaded the lymphatic channels of the patient’s calf and thigh like small bands of wretched amebas. A decision had been made to strike to the quick with an all out therapeutic effort.
In the operating room, G.S. Williamson, M.D., Chief of Surgery and primary surgical consultant to the oncology service, had isolated the arterial and venous conduits leading to and from Charlie Stuart’s entire left lower extremity. The surgeons had then injected into the isolated limb a massive bolus of nitrogen mustard, several times the amount that would have been lethal had it been introduced into the general circulation. At the same operative session, the surgical team had dissected the lymph nodes of the patient’s left groin. These nodes would have been a crucial way station for the advancing hoards of malignant cells as they marched toward Charlie Stuart’s ultimate annihilation. The therapy, though investigational, was logically sound and had appealed to Charles Stuart’s fighting spirit.
Pathological analysis of the lymph nodes removed during the operation revealed no evidence of involvement with cancer. There was cause, at this juncture, for cautious optimism. Fleming peered at the elaborate operative notes. Unless, that is, a small twisting streak of darkness had breached the defenses weeks ago. Were that to be the case, a strike force of invaders might be standing even now upon the ramparts of Charlie Stuart’s lungs.
Fleming noted no indication of any post-operative complications from his review of the medical record. Michele Kelly had mentioned in her note that Charlie Stuart had complained of a splitting headache at dawn. Fleming decided not to awaken Prince Charlie, who appeared to be sleeping soundly with his head protruding peacefully from beneath the sheets.
Behind the draw curtains separating the two beds, Fleming found Castor Cielinski, the younger of the two patients in 291, sitting propped up against the headboard of his bed. With his adjustable bedside stand positioned before him, Castor was shuffling a deck of cards. Fleming noticed that the backs of the cards were imprinted with a medieval couple seated upon a bench within a delicately flowered bower. The word, Amor, was emblazoned upon a gilded shield suspended from the heart shaped branches of a small tree behind them.
"Physician," said Castor, in a half whisper, "observe, if you will, a bit of wizardry with the boards."
After separating the hearts and spades from the deck, Castor arranged the two suits sequentially from ace to king. He then removed the king from the pile of spades and handed it to Fleming. Castor next placed the packet of hearts face down on the bedside table and then began to deal the spades, which he held face down in his hand, face up into two piles. Finishing this, he removed the last card in the pile to his right, the queen of spades, and placed it to one side. Castor then replaced the black queen with the ace of hearts, the top card in the pile of reds. Finally, he recombined the black cards by placing the small pile of spades to his left face up on top of the pile that now contained the ace of hearts. The latter card was now buried in the middle of the reconstituted set of black cards.
Turning the black cards face down in his hand once again, Castor repeated the procedure. This time the last black card in the pile to his right was the jack of spades. This was placed atop the queen of spades and once again he replaced the jack with a red card, the deuce of hearts.
As Fleming watched with increasing confusion, Castor quickly repeated the process until the discard pile contained all of the spades and the pile in his hand contained only hearts. He then placed both piles of cards face down on the table.
"Now, my dear Doctor Fleming," said Castor, almost disdainfully, "I can locate precisely any card you should choose to name."
By this time Charlie Stuart was awake. He had drawn back the curtain separating the two beds. He was intently watching the proceedings.
Fleming was leaning forward from where he stood at the foot of the bed, the better to see. The scene in 291 one reminded him of Bosch’s painting called The Conjuror. Castor was posed for the kill from his side of the game table. Fleming found himself reaching instinctively to his back pocket to check the security of his purse. Castor Cielinski’s collection of tiny mannequins, stuffed owls, and porcelain toads were lying about on the windowsill and nightstand. Interspersed among these were the shell games, amulets, and other props that Castor used during displays of trickery and magic he performed for the entertainment of the nurses, clergy, or anyone else who might be around.
"The five of spades," Fleming ventured, scrutinizing Castor for some sign of deception.
"Aha," said Castor. "We count five cards down into the red stack and what do we find, physician?"
"The four of hearts," Fleming answered.
"Precisely," Castor gloated. "And the fourth card in the black pile is?"
"The five of spades, Castor," Fleming admitted, shaking his head in feigned disbelief. "What else?"
The trick was repeated several times. Without fail, Castor Ceilinski easily located the designated card.
"Ah, but you are skeptical of the sheer puissance of my sorcery," announced Castor, this time with not a little vainglory. He was obviously enjoying the game immensely.
"Please be my guest. Cut the red deck as many times as you would like."
Fleming cut the red deck repeatedly as instructed.
"Very good," said Castor. "Now, please select any number from one through twelve."
"Seven," Fleming responded.
"Exactly the number I would have expected from one so attuned to the mysteries of our silent universe."
Castor baited Fleming with a bemused look of impending triumph beginning to glow upon his face. He quickly dealt the red cards face up into seven piles. Waiting for Fleming and Mr. Stuart to note the arrangement, he picked up the cards again.
"Cut them again, Charlie," Castor said.
"Another number, gentlemen," he demanded next.
"Three," said Fleming.
Again, Castor dealt the cards into three piles and picked them up in apparently random fashion.
"And now, are we quite agreed that the red deck had been thoroughly and randomly mixed?" Castor inquired demurely.
"Quite," said Fleming.
"And so, let us play again at finding knaves."
To Fleming’s utter amazement, despite the obvious random rearrangement of the pile of hearts, Castor was able to locate any designated card just as he had done before.
"Don’t bother asking him how it is done, Doc," Charlie Stuart suggested.
"Trade secret," Castor interjected. "Like the reading of entrails or the understanding of the curative power of enemas."
"I’m not sure I want to know," said Fleming, smiling at Castor whose face was beaming in triumph. "Especially so early in the morning."
Castor Cielinski’s reputation had spread far beyond Corridor O. He had recruited an entourage of student nurses who followed him everywhere like a band of proselytes. He entertained visitors from all over the hospital and held court in his room like a wise and venerable hermit saint. His purported I.Q. was 165. He was twenty-four years old and was strikingly handsome, with a reddish beard and steal gray eyes that could pierce a young woman’s soul like those of an incubus. There were rumors throughout the hospital of nocturnal assignations involving Castor Cielinski.
Castor had agreed to a request from a group of the students to conduct a séance in the solarium on Corridor O at midnight on Halloween night when the moon would next be full. Castor felt an oncology unit would be fertile soil for conjuring the dead. Unfortunately, the Department of Nursing had got wind of the plan and had quashed the idea in no uncertain terms. Michele Kelly had been severely reprimanded for trying to keep a lid on Castor’s plan.
Strangely, Castor Cielinski would die that very Halloween night. His disease, embryonal carcinoma of the testicle with extensive lung metastases, had not responded to Li’s triple therapy with actinomycin D, methotrexate, and chlorambucil. Fleming found it odd that Castor never discussed or questioned any aspect of his illness. His denial appeared to be complete. He continued to preoccupy his mind with occult activities like an imp of the perverse.
On the morning of Fleming’s rounds, Castor had been entered into a Phase I investigative protocol with the drug, mithramycin. His unexpected demise was to be sorely mourned. If not canonized, Castor Cielinski would be at least beatified in the hearts of more than one distraught young woman.
As Fleming was leaving Room 291, he spied a chess piece lying on the floor. After picking it up, he placed the elaborately dressed ivory bishop on QB1 and moved on.
Bending down at the bedside of Adriel Samoy, Fleming checked the level of green amber fluid in the IV bottle that was suspended upside down from the iron frame of her bed. Fleming traced the course of the tubing upward to the point where it disappeared beneath a large white dressing that had been taped to the back of the patient’s chest. Whitish yellow strands of coagulated protein within the lumen of the tubing reminded Fleming of small round worms.
"Are you having any discomfort when you breathe?" Fleming asked the young woman.
"Only a little," she answered, "if I take in a really deep breath."
Her eyes scanned his face apprehensively for any significance her response might have engendered.
No significant fluid had accumulated in the bottle during the previous twenty-four hours. Fleming proceeded with his physical examination of Adriel Samoy’s chest, palpating, percussing, and listening to the sound and feel of her disease. Adriel’s right breast had been surgically amputated, together with the muscles of her chest wall and the lymph nodes in her armpit. The surgery had left only a thin layer of misshapen tissue covering her chest wall. With each breath, this tissue was sucked into the spaces between the patient’s ribs.
Adriel Samoy was one of Fleming’s clinic patients. He had inherited her case from one of the graduating second year fellows in July. Adriel had been coming to Fleming’s Friday afternoon clinic on Angell Center.
Adriel Samoy had been fighting all of her life against the enervating oppression that exists on the streets of the ghetto. She had spent her life where the unwary are unmercifully sucked into the gutter to join the multitudinous ranks of the lost and forgotten whose unsung epitaphs are edged in the black screams of the night. Adriel was thirty-six years old. Her story read like a diabolical fairy tale. She had been raped at eleven. She began skin-popping heroin at thirteen. She had turned her first trick at fourteen. Adriel was pregnant, busted, drunk, or stoned a good part of the time. Breast cancer at thirty-four had come as no great surprise.
Skin implants had appeared along the edges of Adriel Samoy’s surgical scar eleven months previously. Although her age and the relatively short interval between mastectomy and recurrence foreshadowed a poor response to endocrinological treatments, the limited extent of her disease had prompted the tumor board to recommend castration. Adriel had responded. The skin implants had gradually melted away in the weeks following the removal of Adriel’s ovaries.
But on September 18th, Adriel had paged Dr. Fleming complaining of shortness of breath. An examination on Angell Center that afternoon had revealed unmistakable signs of fluid in the right chest, a pleural effusion. Adriel had been immediately readmitted to the hospital.
Fleming had placed a drainage tube into Adriel’s pleural cavity. A fluid sample had been sent to the path lab. Sheets of primitive dark blue cells lay entrapped as innocent harbingers of disaster beneath the cover slip of her cytology slide.
Now, nearly seventy-two hours later, the chest tube had stopped draining.
"I think we’ve got it all," Fleming told her. He was sitting at the side of her bed. "But I want to get another X-ray to make sure. If the picture looks OK, we’ll send you down for the radioactive medicine I told you about."
Adriel’s eyes, edged in anxiety, searched Fleming’s face cautiously. He appreciated her terrible plight. She was torn between an agonizing need to know the truth of her circumstances and the dread of what that truth might be. Fleming could sense a score of questions forming and dissipating in Adriel Samoy’s mind like clouds on a summer day.
"Am I gonna need that operation?" she asked him, finally, after screwing up the necessary courage to address that issue at least.
Adriel Samoy had struck at the heart of Fleming’s own dilemma about her case. The operation she had referred too, bilateral adrenalectomy, would further ablate the ability of her body to manufacture estrogen. She might get another brief remission, but the operation was dangerous and Adriel would have to take cortisone for the rest of her life once her adrenal glands had been removed.
The remission following the removal of Adriel’s ovaries had lasted eleven months. Adrenalectomy might induce a longer remission, possibly lasting several years, but there was no way to know that in advance. Should she not respond to the surgery, without her adrenal glands she would be much more vulnerable to the stresses of chemotherapy. What was the best option, adrenalectomy or chemotherapy? One could make a case for either choice. Fleming tried to make all of the nuances of the decision as clear to Adriel as he could. He knew she trusted him implicitly. The only intervention that seemed clearly indicated at this point was the injection of radioactive phosphorus into her pleural space in order to control the malignant effusion.
"We both need to think a lot more about the operation, Adriel," Fleming concluded.
"When can I see my kids?" she asked.
"If the X-ray is OK, we’ll put in the medicine and take out the tube. I’ll have the nurses wheel you down to the main lobby today or tomorrow, whichever you’d like."
"Thanks, Doc," she said. She touched his arm gently as he stood up to leave.
The patient in Bed 2 was a small, wizened little woman who appeared so ancient and frail that she might break. She spoke in a distinct Slavic accent. Rumor had it that she had once been a gypsy. She was able to speak with Dr. Michailovich in several Eastern European dialects, including a smattering of Romany. Her bedside stand contained a strange collection of amulets and beads.
The right side of the patient’s head was swathed in a large white bandage that extended diagonally from her ear to the left side of her forehead. She was wearing a pair of small horn-rimmed glasses low on her nose. The right ear piece of the frame of her glasses was buried in the bandage, leaving a field of white behind the right lens. She squinted up at Fleming as he approached, craning her neck slightly so she could see him better through the lens of the eyeglasses that covered her good left eye.
Fleming pulled the curtains around the bed and acknowledged the patient’s unspoken greeting with a nod. The orders written in her chart were explicit. The patient’s dressing was to be changed daily, but only by a physician. The little old woman had become accustomed to the established morning ritual. A large supply of fresh dressings was stacked on a small table near the bed.
Fleming carefully removed the patient’s glasses and placed them on her bedside table. Before removing the bandages, Fleming checked a small green Watkin’s arterial infusion pump that was suspended with a tie tape from the patient’s neck. The reservoir of the pump, containing the drug 5FU-dr, was visible through a small window in the front cover. From the side of the pump, a clear plastic tube coursed upward toward a small incision in the right side of the patient’s neck.
The patient’s name was Marta Zaryechny. A basal cell carcinoma of the skin had been slowly eroding the right half of her face for an unknown number of years. Mrs. Zaryechny was convinced that her affliction had been caused by a spell being worked upon her by a witch. Mrs. Zaryechny had explained to Dr. Michailovich that this witch had cast an evil eye upon her in the marketplace of Tuzla when she had been a small child in Yugoslavia. She had tried any number of spells and phylacteries to ward off the encroachment of the minions of the Prince of Darkness.
The skin cancer had slowly grown in size through the years as if enlarged by the nibblings of a band of nocturnal rodents that visited the site of a diabolical feast in the night. The wound now extended across the bridge of the nose in the form of a vast wasteland arching smoothly over the forehead. The ragged lower margin had eroded the cheekbone and the lesion extended laterally nearly as far as the right ear. Sometime during the course of the inexorable erosion, the entire right eye had been eaten away.
Somehow, Marta Zaryechny had managed to conceal the extent of her terrible deformity. She had gone about her domestic occupations done up in brightly colored babushkas that had hidden the hideous ulcer from the sight of her own children.
Mrs. Zaryechny had explained to Dr. Michailovich that she had read somewhere recently that skin cancer can be fatal and so--through an additional quirk of human behavior--she had come to him to seek a cure. The Chief of Oncology had decided to treat this most singular lesion by infusing 5FU-dr into the ulcer’s arterial blood supply through a branch of the external carotid artery. After several weeks of therapy, the wound was indeed beginning to heal at the edges.
Fleming had removed the dressings. He was staring with morbid fascination at the gruesome site before his eyes. Even more grisly than the extent of the wound, was the fact that the skull at its base had been eaten away, leaving the convolutions of the brain clearly discernible beneath a thin veil of covering membrane. The brain and the snakelike arteries that coursed over its surface were pulsating with each heartbeat like a metronome beating time in a dance of death.
Realizing that he had been preoccupied with the sight before him far longer than was appropriate, Fleming quickly replaced the dressing. He felt anxious. He realized that had anyone interrupted him, he might have burst out laughing. He felt like a crazed participant in a psychopathic comedy in the theatre of the absurd.
Marta Zaryechny would continue to respond, but unfortunately she would trip on a slipper one morning, lose her balance, and impale her skull on the sharp corner of her bedside table. She would be found by the nursing staff, with her twisted fingers clutching the air and with small pieces of brain sliding slowly down her chin. Jack Fleming would be called to Corridor O to pronounce Marta Zaryechny dead.
There were two other patients in Room 292, but both of them were private patients of Maurice Dubois. As Fleming had surmised earlier in the lab, Maurice had already rounded on both of them. The two ladies had no need of further attention.
Pushing the chart rack along in front of him, Fleming returned to the hallway outside of Room 292. To his left, looking to the north, he could see the expanse of the long gallery that connected Angell Center and Corridor O. From Fleming’s perspective, the two areas corresponded like the north and south wings of a transept. At the crossing was the nursing station. LPNs and students were bustling about as they went about their business, giving treatments and passing medications. Old Harold was no longer in the hall. Fleming surmised that he had been wheeled back to his bed in Room 293, the second of the four bed wards. To Fleming’s right was the solarium. He decided on impulse to walk into the room. The solarium was one of Fleming’s favorite places.
A small plaque on the wall next to the arched entrance informed the visitor that the solarium had been constructed in memory of a person called Constance Younger. The date of the bequest was no longer discernible.
The spacious room was embellished in unmistakable Gothic accents. The smaller east and west walls and the larger wall to the south were pierced by a series of windows with transoms and mullions. The grisaille glass of the windows was hatched in a pattern of diamonds. The windows had arches atop them that were adorned with a flamboyant tracery of lacey delicacy. The spandrels between the arches were alive with angelic beings carved in varying degrees of relief. The muntins holding the panes of glass to the sashes were profusely decorated with sculpted vines and leaves. Above the windows, the walls of the solarium featured a cornice of hand carved wood. Near the ceiling, the decorative ensemble was completed by a march of small stained glass windows.
The sun was now rising in the southeast. Rays of light penetrated the room, producing a blaze of illumination. Brilliant splashes of light were intermixed with luminescent zones of color that played over the rich flora of the room and along the parquet floors. Fleming found the effect breathtaking.
As he scanned the sanctuary, drinking in the effects of the sun and the intriguing details of the complex architectural program, Fleming was suddenly overcome by listlessness. The solarium seemed completely out of tune with the general mood of the hospital. A nostalgic sadness inexplicably passed over Fleming. He had to force himself to leave the solarium to continue his rounds.
"Fifteen, sixteen, seventeen, eighteen."
Chip Caldwell was energetically calling cadence to a series of Marine Corps style push-ups, as Fleming pulled the chart rack into Room 293. With each count, Caldwell would jerk his upper body free of the floor with his muscular shoulder girdle, clap his hands loudly with a sharp smack, and then quickly reposition his hands upon the floor so his wrists could absorb the weight of his lean and powerful torso.
"Twenty-four, twenty-five, twenty-six."
The fifty push-ups would be followed by two hundred sit-ups and a score or two each of several other punishing calisthenics, done religiously each day at the side of Caldwell’s bed.
Thick, bluish veins stood out like stovepipes along the rock hard muscles of Chip’s neck. The sweat pouring in rivulets from his suffused and congested face collected at the chin and was sprayed into the air with the shock of the push off and set position of the exercise.
Fleming stood perusing the chart as Caldwell completed the number of repetitions specified by his morning ritual.
"Forty-eight, forty-nine, and fifty!"
Caldwell’s voice strained with the rigorous combat between vocalization and breathing.
Chip sprung to his feet and swung himself, like a gymnast, up onto the bed. He sat there, exuberantly anticipating any ministrations Fleming might have in store. Increased excursions of his thorax as he breathed were slightly perceptible.
Spec 4 Arthur Caldwell had taken a hit outside Loc Ninh near the Cambodian border in May, l968. He had been extremely lucky. The missile had caught him tangentially just beneath the left nipple, causing only a flesh wound. A slightly different angle and he might have taken a direct heart shot. A mandatory chest X-ray at the 130th Field Hospital had shockingly revealed small, rounded, nodular shadows in both lungs.
Chip had been air evacuated to Walter Reed Army Hospital ten days later, two and a half months short of the end of his tour in Viet Nam and thirty days shy of his twentieth birthday. Work-up at Walter Reed had failed to turn up a primary source of the lesions in Chip Caldwell’s chest. He had then been subjected to a limited thoracotomy to establish the diagnosis.
The pathologists had winced at the tormented lesion impaled upon the slides. They had not been able to grace the tumor with a name. The experts in histopathology at the Armed Forces Institute of Pathology, to whom Chip’s biopsy had been sent for an opinion, were equally puzzled. The lesion had been signed out as a list of nine possibilities, most of these unusual soft tissue sarcomas. The only consensus was that Chip’s cancer was primitively young, prolifically alive, and arrogantly deadly.
Arthur Caldwell had been medically discharged from the United States Army with full disability and benefits. He had been transferred to the suburban Veteran’s Administration Hospital to the west of the medical center, in order to be closer to his family. Conventional chemotherapy had failed to check the slowly progressive growth of the malignant nodules in his lungs. Through a special arrangement with the Veteran’s Administration, Chip had been transferred earlier in the week to Angell Center. He had been admitted to Corridor O for more aggressive therapy.
The drug chosen for trial was NSC-45388, also known as imidazole carboxamide dimethyl triazeno, or ICT. Baseline laboratory studies had been completed and the first five-day intravenous course of the drug would begin on Monday. Chip had inveigled a weekend pass out of Dr. Michailovich. He was impatiently awaiting Fleming’s authorization permitting him to leave. In the interest of time he had decided to forego the five trips at full gait up and down the back stairwell, from the basement of the hospital to the pavilions on the fourth floor, that were part of his daily routine.
Fleming listened to Chip Caldwell’s lungs with his stethoscope. The disease was silent and unrevealing.
"What do you say, Doc?" Caldwell was taut as a tightly strung piano wire.
"What’s on the agenda, soldier?" Fleming asked.
"Oh, man, I have got this thing goin’ with a lady you would not believe! Tonight is definitely party time."
"Action’s pretty good on the home front, is it?"
"Hey, you better believe it, man! I come on to the ladies like a choirboy, you know. Like I’m just a humble little war hero. Naturally, they want to feel all of my wounds. And if that don’t get’m, I start talking about how I got cancer and not long to live. Before you know it, they’re all broke up and sobbin’ all the way into the back seat of my Chevy."
"Well, listen Caldwell," said Fleming, writing the release.
Stay the hell out of jail, OK?"
"Amen!" Chip responded, bounding out of bed like a gazelle on his way to the shower.
Fleming wheeled the portable chart rack to the foot of Old Harold’s bed. The rack had a slanted support attached, so the charts could be placed in position for easy reading. The apparatus resembled a lectern. As he stood at his pulpit, Fleming felt like an Archbishop about to address a congregation of one. He wondered what words of consolation he could offer Old Harold, heckler and heretic, who was watching Fleming intently, with a threatening gleam in his eye.
Old Harold, thou hast sinned grievously.
Old Harold, thy liver shall be measured even unto all the days of thy life and thy blood, yea, even thy blood, shall be brought up out of thy veins and delivered in vials into the hands of thine enemies in the Land of Laboratorium. And thy carcass, covered over with emerods, shall lay stinking in thine own fields and thy flesh, yea, even thy flesh, shall be eaten by worms and by lupins and by the four-footed fowls of the night.
Fleming slowly turned the pages of the medical record, perusing the nebulous connection between Mr. Harold Courtnay, human being, and Old Harold, the bronchogenic CA in Room 293. Fleming saw that all was good. The necessary tests had been ordered. Old Harold was soon to become a novitiate, duly conscripted, into the ranks of the faithful. His chemotherapy, too, would begin on Monday morning.
"Blasphemers!" muttered Old Harold. A huge distorted and embossed forehead disappeared beneath the sheets, as Friar Jack of the Shriveled Tongue moved on to the next bed.
A rubber balloon, cylindrically shaped, eighteen inches long and four inches in diameter, hung from an IV pole next to Bed 3. The balloon was constrained within a gray jacket of unyielding silk mesh. An intra-arterial infusion bag was tightly compressed between the balloon and jacket. IV tubing leading from the infusion bag disappeared beneath an Ace bandage that encircled the patient’s right upper extremity at the level of the elbow. The patient’s name was Martin St John.
The IV tubing was connected to an arterial catheter, which had been skillfully threaded into Martin St John’s hepatic artery by Otto Tumarkin, G.S. Williamson’s younger colleague on the surgical service. The hepatic artery supplies the liver with blood. A chemotherapeutic agent was being infused directly into Martin St John’s liver where legions of malignant arachnids were spinning webs of resistance at many outposts of invasion. Twenty-four hours each day, the drug slammed in for the kill like waves of phosphor traced missiles screaming over the battlements. As Fleming checked the infusion pump, he imagined a phalanx of seraphim in pitched battle upon the barbicans with a band of rebel angels.
Martin St John had been in excellent health until he had been overcome by insidious fatigue, which his family physician had attributed to "tired blood." Perhaps as a high school principal he should have known better. Six months passed before Mr. St John’s wife discovered a knobby swelling in the right upper aspect of her husband’s abdomen. A tragically belated work-up had uncovered an exuberant adenocarcinoma proliferating in the ascending segment of Martin St John’s large intestine. The malignancy had already metastasized to the patient’s liver. The disease was incurable from the beginning, but a limited resection of the bowel had been done as a palliative measure to prevent obstruction or hemorrhage.
Mr. St John had been informed that the termination of his life, heretofore ill defined, was becoming distinctly encapsulated within feebly whispering moments of time. In the estimation of his surgeon, chemotherapy would not be effective. Oncology referral would be grasping at straws. Martin St John had consulted Dr. Michailovich, clutching the entire hay wagon with every aspect of his being.
Semyon Michailovich had presented Martin St John with two options. The administration of systemic chemotherapy with conventional and then investigational agents was the first of these. The likelihood of response was not good. The patient might have a 25% chance of survival for six months to a year. Death would be painless, a consequence of progressive liver failure with terminal coma.
A second option could be considered because the disease appeared to be confined to the patient’s liver at this juncture. The infusion of anti-neoplastic drugs directly into the arterial blood supply of the liver might control the disease for one to two years, or perhaps longer.
There was a downside, however. Patients choosing hepatic artery perfusion face greater suffering at the end because of painful invasion of the bones and nerve roots. Such pain is difficult to control, even using the strongest narcotics. Given the alternatives, Martin St John, forty-three years old with two young sons, opted for time.
Fleming checked Mr. St John’s temporary trans-brachial artery infusion system. The plastic bag containing the medication would have to be changed later that afternoon.
Once it became clear that the disease in the liver was responding to chemotherapy, the surgeons would implant a permanent catheter directly into the hepatic artery. A Watkins Model 207-E portable pump would be connected to the catheter. The reservoir for medication would need to be refilled once each week. Using this system, the patient is afforded unimpeded mobility.
Fleming made careful measurements of Martin St John’s liver. Reference lines had been drawn on the patient’s skin with an indelible marker. There was no question that the liver was diminishing in size. Unequivocally, the disease was responding to treatment.
"Road maps of the soul, those little lines of yours, wouldn’t you say, Doc?" Mr. St John suggested. Fleming was completing his assessment of the dimensions of the involved organ with the intensity of a medievalist at work upon some ancient tome.
"I suppose you could say that," Fleming answered, somewhat preoccupied. "It’s looking very good."
"Yes," said Mr. St John, "I can see that."
"I’ll be back to change the bag about two o’clock," Fleming said.
Mr. St John nodded in affirmation.
Fleming maneuvered the chart rack past Bed 4. He reflected momentarily on its stark emptiness. Bed 4 had been occupied by Matthew O’Brian. Mathew’s name, hospital number, and location had been deleted from the Angell Center list earlier that morning. Matthew, age l6, had expired at 4:30 A.M. of non-Hodgkin’s lymphoma. Michele Kelly had related a chilling story when she had called Fleming at home to inform him of the expiration. Matthew’s mother had been maintaining a vigil at her son’s bedside throughout the night. Once Matthew had stopped breathing, his mother had gotten into the bed with him and lay there pleading with the boy to wake up. Several minutes elapsed before the nurse’s had been able to lead her from the bedside. The disruption had awakened everyone on Corridor O, including Old Harold.
According to Kelly, Old Harold had gurgled on scornfully for about an hour, calling all of the staff murderers of young children, before he had finally fallen off to sleep again.
"Molly? Can you hear me, Molly? It’s Dr. Fleming."
Molly Shaw remained unresponsive, in deep coma. When she exhaled, the paralyzed left side of her face puffed outward like an opening parachute. Her left cheek and the left side of her mouth fluttered like a sail caught in the wind with each breath. Each exhalation produced a guttural sound that was both repulsive and strange to the ear.
Molly Shaw’s mother, two of her maternal aunts, and an older sister had died of cancer of the breast. She had grown up obsessed by an immutable fear that she too would succumb to the family nemesis. Her defense against the disease had encompassed everything short of prayer or prophylactic mastectomy. She rejected both of these, the first as ineffective, the second as inconceivable.
The disease had struck mercilessly and with unrelenting fury at age twenty-four. Within three months, Molly Shaw had lost both of her breasts. In less than six months, the disease had metastasized to every part of her body.
Molly had never recovered from the emotional trauma of such a horrible end to her life. Her state of mind in the final weeks before the merciful onset of her coma had seemed to Fleming a prolonged agony. Molly’s existence seemed to be playing out in time lapse those last few instants when the victim of an execution experiences the flash of the gun fire, the whine of the great blade descending, or the feel of space as the trapdoor falls away.
The neoplasm had swept across the meningeal membrane encasing her brain like a tormented brush fire driven by a hot summer wind, incinerating in its path the nerve roots at the base of Molly’s skull. Her spinal fluid was teeming with cancer cells.
Molly Shaw had become a veritable museum of neuropathology as her cranial nerves had been destroyed one after another. The 12th, the hypoglossal nerve, had been the first affected. With the loss of motor control of the left half of her tongue, Molly’s speech became impaired. She sounded like a person trying to speak with a mouth full of marbles.
With the destruction of the 10th cranial nerve, the vagus, a nasal twang had been added to Molly’s voice. She had soon become unable to drink without choking. Liquid phlegm gushed from her nostrils in embarrassing torrents of tearful apology. The 7th, or facial, nerve had then been lost. The collapse of the left half of Molly’s face left her incapable of normal expression. She was no longer able to close her left eye. As the epitome of irony, Molly Shaw required the periodic administration of artificial tears. Her natural tears, profuse as they had become, were inadequate to prevent the desiccation of her corneas.
Finally, the disease destroyed the occulomotor and abducens nerves. Molly Shaw assumed the appearance of a hapless and cross-eyed doll with asynchronous and broken rhythms to the movements of its eyes.
Therapeutic efforts in Molly Shaw’s case had been nothing short of heroic. She had been given injections of methotrexate directly into her spinal fluid. Her brain had been irradiated with Cobalt 60. The neurosurgeons had reluctantly drilled a small channel for the delivery of chemotherapy into the very center of her brain. Still, Molly had not responded to a single element of the treatment meted out to her for this strange and bewildering illness. She had been cast adrift upon Corridor O, a tit-less wonder with a wrecked and twisted face. She had uttered her final garbled lines like a deaf-mute crying out to an unresponsive world.
Molly Shaw’s left eye had been taped closed by the nursing staff to keep the cornea from drying out. Fleming carefully replaced a lock of hair that had fallen across the adhesive into its natural position. There was nothing else he could do for her.
Molly had been so very beautiful.
Mrs. Durrell, in Bed 2, also had breast cancer. She was recovering from an episode of acute hypercalcemia. The calcium in her blood had reached levels as high as 18 mg/dl following the treatment of her disease with high doses of estrogen. Mrs. Durrell was doing fine. Her discharge home was anticipated for the first part of the coming week.
Lottie Durrell had shared her story with Fleming and with most of the other members of the staff. She was 68 years old. She had been blessed with a good life. She and her husband, Leonard, had raised three sons of their own, plus the cast off wraith of an unfortunate union between Leonard’s good for nothing sister and some travelling salesman or Mississippi gambler. Mark was the lad’s name. His mother was in her grave with the consumption. The gambler had hit the road long ago. Under the tutelage of the family, Mark had grown up to become a fine young man.
Fifty-two years they had been together, Lottie and Leonard, accepting the will of the Lord through thick and thin. Lottie’s religion had sustained her over the years when the bad times had come. They had lost Tom, their eldest, in the Pacific in 1943. Lottie had had her own brush with cancer in 1951. She had lost a breast to it, but Leonard, dear man, and the Lord had given her the strength to bear it.
In his later years, Leonard had suffered with angina. This spring, he had died suddenly. She knew she should not have agreed, but he had pestered her so to be with him, she had finally given in. He was sitting on the bed afterward and had just grabbed his chest and said, "Well, I’ll be damned."
Leonard was dead before he hit the floor.
Lottie had held her grief inside for the boys and Mark. She had carried herself with dignity through the funeral. Three months later, the cancer had been found in her bones. She was sure Leonard was calling her back to him.
Estrogen therapy in post-menopausal women like Lottie Durrell occasionally causes an outpouring of calcium from the skeleton into the bloodstream, the so-called "estrogen flare." Mrs. Durrell had been severely dehydrated at the time of her admission to Corridor O, but kidney failure had been prevented by aggressive treatment of her problem with IV fluids and corticosteriods.
Fleming’s task this weekend was to monitor Mrs. Durrell’s calcium level closely as the IV infusion was slowly tapered. Her latest calcium, drawn on the 18th, had fallen to 11.3 mg/dl, a dramatic improvement since admission four days earlier.
"Is there nothing you can do for that poor girl?" Mrs Durrell asked with compassion, gesturing toward Molly Shaw.
Fleming retreated, gesticulating postures of helpless empathy.
"No, I’m afraid there’s nothing more we can do," he said.
Winslow Harrison looked up as Fleming pushed the chart rack into Room 295. The droop of Winslow Harrison’s right eyelid was immediately apparent. He was running trills on a clarinet. He was playing softly, not to disturb anyone so early in the morning. His roommate, Maxwell Jackson, was keeping time, running his hands over the keyboard of an imaginary instrument, perhaps an ancient harpsichord.
Winslow has having difficulty with control of the fine movements of his right hand. He was losing a note now and then. His face displayed an occasional grimace of frustration and aggravation. Fleming thought he might have detected a faint scent of marijuana coming from the latrine. He decided the aroma was incense, at least for the record.
Sheet music was scattered about on the floor or on the bedside stand next to Winslow Harrison’s bed. Coming from somewhere in the background, Fleming could hear the faint sound of gospel music.
"At last, the man with the Percodan," Harrison said. He carefully placed the instrument beside him on the bed with his good left hand. "We got to get a little higher."
"That you, Baby Doc?" said Jackson. His head bobbed as he sat in his bed. Fleming stared briefly at the empty sockets where his eyes had been. Jackson appeared to be following the cues of his hyper-acute sense of sound.
"We of the choir of angels, who are about to die, salute you!" said Maxwell Jackson. "The dude with the pills and the power to pass," he added dramatically.
Winslow Harrison was the professional. He had been working a combo in a small club off the Cass Corridor near Forest Avenue, until recently. Maxwell Jackson was a sympathizer and aficionado of sorts. Maxwell did not play an instrument. He could still carry a tune if pushed, however. He was not at all displeased by his fortuitous placement in a room with Winslow Harrison. He referred to the clarinetist affectionately as his main man. A strange camaraderie had blossomed between the two patients.
Winslow Harrison’s near lifelong habit of chain smoking cigarettes had caught up with him at the age of 39. The squamous cell carcinoma that would soon end his life had originated in a sulcus nestled at the apex of his right lung. From this primary locus, the tumor had eroded the first rib and had then invaded the soft tissues of the patient’s neck. The malignancy had compromised the integrity of the neurovascular bundle supplying Winslow’s right arm with blood and electricity. Encroachment upon the superior cervical ganglion had destroyed the sympathetic nerve fibers en route to his right eye, hence the signature drooping of Mr. Harrison’s right eyelid.
Winslow Harrison’s cancer had been inoperable from the beginning. The Cobalt 60 he had been given had been unable to contain the flight of a brood of screaming eagles that had swept from the mother nest. Squadrons of deadly minions had implanted roots throughout Winslow’s body. Investigational chemotherapy was now his only chance to regain enough fine motor control to kick out one last mournful set before the curtain fell.
Turning his attention to Maxwell Jackson, Fleming prepared to replenish the gelfoam and thrombin packing that was controlling the bleeding from both of Maxwell’s enucleated orbits. Melanoblastomas do not usually develop in black people. The incidence of these deadly tumors is usually inversely proportional to the degree of pigmentation of the skin. The disease is much more common in albinos. Melanoblastomas do not usually arise in the retina of the eye.
Maxwell Jackson, a black man, had developed, simultaneously, melanoblastomas of both eyes. His was definitely a reportable case. The ophthalmologists, in an effort to save his life if not his sight, had scooped out Maxwell’s orbits. He had been left with two gaping sockets that reminded Fleming of the lead staggering figure in Bruegel’s Parable of the Blind.
Unfortunately, the margins of resection had not been tumor free. Despite irradiation therapy, the disease had recurred in the base of each wound. Melanoblastoma was now proliferating there unchecked, like some dark and ominous fungus. The lesions would bleed at times, leaving jagged streams of blood coursing down Maxwell’s cheeks like rivers of melting candle wax. Packing the orbits with gelfoam and topical thrombin seemed to be stemming the flow of blood. Maxwell lay there wailing bluesy melodies from deep out of the South in a throaty whisper, until Fleming had finished packing the patient's eyes..
Winslow Harrison called Maxwell, Oedipus, and Michele Kelly, Antigone. He cracked up that the significance of this was lost on both of them.
A drawn and haggard figure of the Nazarene graced a simple rood mounted with surgical tape to the wall at the entrance to Room 296. As Fleming passed the crucifix, the rays of the morning sun, still rising in the southeast, blinded him momentarily. The pellucid atmosphere of the chamber was suffused with a shimmer that eclipsed, in glinting flashes, the candlelight flickering at either side of a small altarpiece that was perched upon a stately cabinet near the window. The cabinet was draped with a rood cloth, imbuing the ensemble with the sanctity of a chancel table.
A nimbus of sunlight circumscribed the head of a shrunken figure propped against the headboard of the single bed in the room. The intense light obscured the details of the face. The patient was reading from a gilded text.
"Good morning, Father Brautigan, I’m Dr. Fleming. How are you feeling today?"
"I’m dying, Dr. Fleming," came the vitriolic response. "How do you suppose I’m feeling?"
Fleming had not encountered Father Brautigan before. There had been an implication at paper rounds the day before, however, that the patient in 296 was difficult.
"I didn’t mean to sound disrespectful, Sir. I was just wondering…"
"Wondering what, young man? Have I been able to defecate? No, I have not been able to defecate for several days. What of it?"
"Perhaps I could order something?"
"Let me ask you something, Dr…Dr, what was your name?"
"How will I die of this disease, Dr. Fleming?"
The question was direct and unexpected. Fleming was taken aback by it.
"Father Brautigan," he said, "with the treatment that is planned for your condition, there is every hope..."
"Now listen, Damn you! Don’t you dare give me any platitudes about hope! I asked you a question and I expect an answer. How will I die of this disease? Will I hemorrhage? Will I choke to death? Will I die in pain?"
"Father Brautigan, I really don’t know."
"You don’t know!??"
"Then what the hell are you doing here?"
"Well, I’m in the training program…"
"What training program?"
"It’s a fellowship in oncology, which is…"
"What does that make me, then, one of your little guinea pigs?"
"No, not at all."
"You get the hell out of here, do you hear me? Get out of this room right now!"
Fleming flushed, as he edged toward the door. An incredible urge to retaliate was tearing him apart.
"I’m sorry, Sir," he said despondently.
"Do you know Kierkegaard, Dr. Fleming?" the priest asked, in a suddenly cheerful and melodious tone.
"Who?" Fleming asked.
"Soren Kierkegaard, of Denmark. We Jesuits cling to Kierkegaard like a drowning man might cling to a stick."
"No, I’m afraid I’m not familiar with him," Fleming confessed, with chagrin.
"Do you read?"
"Well, yes, of course."
"What do you read?"
"What? I don’t…"
"Textbooks? Journals? Medical garbage, am I right?"
Fleming’s anger was reaching the boiling point. He was experiencing a perverse desire to tear "Father" Brautigan apart, literally and/or figuratively.
"You happen to be an atheist, are you not, Dr. Fleming?"
"No, I’m not an atheist!" Fleming said heatedly.
"Oh? What is your position, then?"
"What do you mean, my position?"
"In time and space, you fool! What is your metaphysics? What is your philosophy, Doctor?" the priest responded, his voice now a bizarre whisper.
"Look, Father Brautigan, I’m afraid I have other patients to see," Fleming lied. "I really must be going."
Any presumption Fleming had previously held that deeply religious people would be resigned to death and anxious to be with Jesus had been rudely crushed by Father Richard Brautigan.
"Is there is anything I can do for you, Father?" he asked, feeling totally impotent and defeated by his realization that he had no idea how to help this dying priest.
"Give me the answers! Father Brautigan cried out. "Give me the answers," he repeated in a hoarse whisper.
The older man’s frail body was wracked by a convulsive sob. He covered his face with the book he was holding. His muffled speech echoed into the room from behind the finely sculpted Moroccan leather binding of his copy of The Liturgy of the Hours.
"There can never be a reconciliation between reason and faith," he mumbled. "I should have known better. So much thinking! I was certain the order would show me the way, but there isn’t any. Night after night I’ve spent in libraries, even at the Vatican, torturing my flesh, castrating my mind.
"Better for me, for you, for all of us to believe, simply and humbly, with every hair on our miserable bodies. But I cannot! I cannot believe any longer. My life is at an end, and I can no longer believe. Can you imagine the torment of that? I could tear out my brain with the madness of my disbelief.
"I have given away my one little life. I want that sacrifice justified. Do you understand me? I have given away my life. I have never wallowed in the sweet smell of sex like a pig in the mire, such as you must do, Dr. Fleming.
"Now I must die and the worms will suck out my eyes and pour from my hollow mouth. The horror of that image haunts me, Dr. Fleming. If only there had been no thinking, no reading. The church should never give us the time to think."
Father Brautigan allowed the book to fall from his face. He placed in on the bed beside him. After a brief pause, he looked up at Fleming.
"Who are you? What do you want?
The old man’s voice was now soft and pleading.
"Father Brautigan, is there anything I can do for you?"
The figure receded into itself, wrapping the hassock tightly about its skeletal form. The hands, with beads entwined about the bony fingers, gently lifted a hood over the face. A passing cloud cast the room into momentary shadow.
"Get out!" was the vituperative reply.
Fleming was having coffee with Ruth Ciano, R.N. Mrs. Ciano was the day shift charge nurse for the weekend.
"Our friend in 296 is something else," Fleming suggested.
"Yeah, some priest. One of the aides swears he was doing something not so nice in his bed Thursday morning."
"You must be kidding!"
"How does he get away with the candles?" Fleming asked. "I thought open flames were against fire regulations in hospitals."
"Beats me," the nurse admitted. "He says on admission I’m burning candles and that was that. Dr. Heller told us not to bother him about it."
Fleming shook his head slowly. He watched lines of indignation etch their way across Mrs. Ciano’s pleasant face and then dissipate.
Suddenly, a breathless and excited aide burst into the lab.
"Dr. Fleming! 290, Bed 2. You better come right away."
Loretta Pottersfeld had backed into the far corner of the room. She was standing with the call button in her right hand. Loretta was staring at the form in Bed 2. The back of her left hand was pressed firmly against her mouth. Her eyes reflected shocked disbelief.
Fleming rushed to Karen McCaffrey’s bedside.
The patient’s head was tilted back. The dark hole that represented her mouth was exuding a series of strange gurgling sounds. Her eyes were wide open and glazed. The dark pupils were limpid pools of deathly stillness.
Karen McCaffrey belched. Her body then shook tremulously. She sucked in a prolonged shuddering inspiration. Her head jerked backward even farther. Air rushed through her mouth as a strident and urgent gasp.
Fleming placed his stethoscope near Mrs. McCaffrey’s heart and listened.
The body gasped once again before relaxing into the bed. The mouth exuded a last series of gurgling sounds. A large bubble slowly formed at the lips and then burst. The bowels evacuated audibly.
Fleming opened a small case he had retrieved from his coat pocket. Removing the instrument from its case, he assembled his ophthalmoscope. With considerable deliberation, Fleming searched the patient’s retina. The columns of blood in Mrs. McCaffrey’s arterioles had become disrupted to form what were known as "boxcars." This was a classical sign of complete and irreversible cardiac arrest.
Fleming stood up. He slowly disassembled the ophthalmoscope. Finally, he replaced it into one of the pockets of his long white coat.
As he turned, Fleming’s eyes met those of Loretta Pottersfeld. There was no need to say a word. Her face told him everything.
Because some of the patients on the oncology service were on seven day per week drug schedules, injections were given to outpatients on Angell Center on Saturday and Sunday mornings. The outpatients were instructed to present themselves at 10:00 A.M. They were forewarned that a short wait might be necessary.
The space allotted to the oncology center that lay farthest to the east consisted of several rooms, each with a specific function. One entered this area from the center of the hallway that connected the Angell Center waiting room and lab with Corridor O, directly opposite the inpatient nursing station. Proceeding directly to the east, one passed on the right the outpatient nursing station, a drug preparation unit, and a general work room. To the left was a larger space that was used for outpatient procedures. Straight ahead, at the eastern terminus of Angell Center was the high altar, as the fellows had christened the offices of Dr. Michailovich and his personal secretary, Arlen Beckett.
After making arrangements to meet with Karen McCaffrey’s husband when he arrived at the hospital, Fleming entered the Angell Center outpatient facility. Because of a large volume of traffic confined to a relatively small space, this area teemed with activity during the regular week. The ebb and flow of humanity and the outdated architectural features of the space combined in Fleming’s imagination to create an atmosphere that seemed displaced in time. The congested scene here was often fascinating. Patients cautiously negotiated the unfamiliar nooks and crannies like pilgrims exploring an ambulatory. The nurses, like the angels of mercy of a medieval Hotel Dieu, busied themselves with ministrations to the sick. Physicians scurried about, coming and going like priests. A procedure might be in progress, conducted ritualistically like a formal christening. At other times, a cadre of patients might be sitting awaiting their medications like communicants anticipating the Eucharist.
The solitude on the weekends appealed to Fleming. He liked to retreat to the cloistered sanctuary of Dr. Michailovich’s office, which was always left open to the staff. The professor’s desk and personal microscope—a magnificent Leitz binocular—filled a third of the available space. The desk was cluttered with journal articles, slides, and the many artifacts that had been gifts from patients and their families. The remainder of the room served as a general conference area and departmental library. Two couches and several lounge chairs abutted a series of closed cabinets. These were filled with ancient tomes, collected by Semyon Michailovich like apocrypha during a lifetime of erudite study. A small conference table stood in the center of the room.
On Friday afternoons, weekly paper rounds were conducted in Dr. Michailovich’s office with the sobriety of ecumenical councils. The fellows, as novitiates, were expected to briefly present the essential details of each case to the group at large. The senior physicians commented sagely like archbishops at a synod.
The atmosphere of the professor’s office was warm and inviting. Two orieled windows fitted with leaded glass panes drew in the sunlight. There were aging photographs of several of Dr. Michailovich’s own professors in stiff old country poses, together with portraits of Beethoven and Mozart, mounted to the single wall not given over to the storage of books.
Fleming entered the professor’s office and sat down. He had established the habit of spending a few moments alone here when he was on call. He allowed his mind to become beclouded by a thoughtless and relaxing stupor, as he peered vacantly out of the windows at the surrounding slums of the city. He tried not to think about Karen McCaffrey.
After a few moments of relaxation, Fleming left Dr. Michailovich’s office. He returned to the drug preparation station, where he mixed and drew up into syringes the medications he was to administer that morning. He called his first patient and led her to a special chair located in a corner of the procedure room. The chair was fitted with an adjustable arm rest and a supply module replete with needles of every gauge, a collection of tourniquets, alcohol sponges, and dressings. The patients called the apparatus "the rack."
"Are you sure Dr. Heller is not in the hospital today? My veins are so bad. They have such trouble finding them and then they pop almost every time. I just can’t stand all of that poking around. It drives me crazy."
Fleming placed a tourniquet loosely around Mrs. Lousyvein’s arm. He then wrapped her antecubital fossa with a warm towel. The patient was sighing and sweating, but she was firmly yoked to the rack.
"Only one stick now, you promised. Last week, they had such a time, you wouldn’t believe."
Fleming tightened the tourniquet. The patient’s knuckles blanched white as cue balls as she tightly clenched her fist. She did have terrible veins.
"Oh, Jesus, don’t let me faint!"
Hitting veins is an oncologist’s forte. It has to be. Knowing all of the fertile ground, talking up veins, rubbing them up, anticipating the patient’s sudden moves, holding veins down, all of this was part of the challenge. Veins could be as slippery as greased pigs and as uncooperative as infants, but after two months on the oncology service, any one of the fellows could have turned fifty bucks a night working as a hit man for the junkies out on the street.
"You mean it’s over? I don’t believe it! I didn’t feel a thing."
Fleming had injected a combination of 5-fluorouracil and Cytoxan into the patient’s bloodstream. The drugs would disappear without a trace within hours, but they would persist in hiding for many days. During the period of their lethal influence, the two chemicals would inflict fatal biochemical wounds on any cell in need of replicating its DNA for the unquestioned purpose of procreation, whether that cell was normal or malignant.
Stat Call: Corridor M, Mary, Room 196, Bed 2
Rounds completed, Dr. Fleming and Dubois had reconnoitered in the hospital cafeteria for lunch. The Angell Center patient list had again been updated. The names of Karen McCaffrey and Marcus Letterman, a patient discharged home by Maurice Dubois, had been deleted. Fleming had returned to Room 290 and had had a long talk with Loretta Pottersfeld. He had arranged her transfer off Corridor O. Three patients from the outlying floors had been transferred into the empty beds on the oncology unit. Then, Maurice Dubois had been called in emergency consultation to one of the nearby hospitals. Fleming was left in charge of the service.
Frank McCaffrey had taken the unexpected death of his wife extremely hard. He had consented, with reluctance, to Fleming’s importuning about an autopsy.
Fleming had just left the basement morgue, after checking on the time of Mrs. McCaffrey’s post, when a stat call came in as a flutter of closing pages. An urgent and excited voice called from the public address system with insistence.
"Dr. Fleming, stat! Dr. Fleming, stat!"
Fleming picked up the call and then rushed toward Corridor M-Mary. A massive sympathetic discharge flooded his bloodstream with catecholamines. Fleming’s swollen musculature drove the fluid articulations of his skeleton up the staircase, as he charged toward Room 196. His heart was pounding and his fists were clenched. As usual, in such situations, Fleming was aware that he was afraid.
The patient in Bed 2 was unresponsive. He appeared to be in profound shock. His face was deathly pale, his pupils were widely dilated, and his skin was drenching wet with algid sweat. Fleming immediately noticed that the IV bottle hanging from the stand next to the bed was empty.
"Get me 50cc of 50% dextrose in water, fast!"
The disquieted student nurse in striped pinafore and angel’s wing hat looked at Fleming with an expression of wretched and utter disbelief. Anguished words of protest began to reach her lips as he cut her off abruptly.
"I said, get it. Now!"
Fleming waited impatiently. His finger’s monitored the patient’s radial pulse. He could feel the eyes of the three patients on the ward burning into the scene.
The student was back quickly. She thrust the syringe at him shakily.
Fleming injected candied apples, watermelon sugar, Maple syrup.
The response was dramatic, confirming his suspicion of hypoglycemia. Fleming could appreciate audible murmurs of approbation in the background, extolling the patient’s safe return from a sugarless abyss.
"Please get the next IV and hang it," Fleming said to the still mortified student.
The patient was now fully awake and appeared none the worse for the experience. Fleming explained to him what had happened and instructed the patient and the other three men in the room what to do should the level of fluid in the IV ever fall to a critical level in the future.
Back at the nursing station, Fleming reviewed the patient’s medical record and wrote a brief note about the incident. The student was devastated. She appeared close to tears.
"You handled that well," he said.
"Do you understand what happened?"
"Follow along with me," Fleming suggested. "Your patient has hepatic failure because his colon cancer has metastasized to his liver. To prevent coma, his dietary protein has had to be restricted, so he is being fed intravenously with concentrated glucose infusions.
"How does his pancreas respond to all of this sugar?" Fleming asked.
"By secreting insulin," the student offered tentatively.
"Exactly! And so, if the infusion stops abruptly for any reason, the pancreas doesn’t get the message right away. Insulin keeps pouring into the bloodstream at the same rate. What do you think that does to the patient’s blood sugar?"
The student dramatically held up her hand with the thumb pointed directly to the floor.
Fleming nodded affirmatively.
"The R.N. is gonna have my ass for this," said the student.
Despite Fleming’s reassurances to the contrary and his promise to talk to the charge nurse on the student’s behalf, the young woman remained utterly disconsolate.
Corridor C-Charlie, Room 302, Bed 1
"I just can’t understand what could possibly be wrong with me, Dr. Fleming."
Fleming was sitting in a chair at the patient’s bedside, taking notes and listening, as Isabel Abrams, his first admission of the day, related her story. Mrs. Abrams was 72 years old, but she looked no older than fifty. In l965, she had undergone operative resection of an adenocarcinoma of the descending colon. She had remained free of recurrent disease until July of the current year. A routine chest X-ray had detected metastatic nodules in her lungs. Chemotherapy with 5-fluorouracil and methotrexate had failed to effect a remission.
"Can you imagine? There I was, standing outside of my car, trying to open the door with my car key, when this man steps up to me and orders me away.
"That’s my car you’re trying to get into, lady," he tells me.
"You must be mistaken," I told him.
"No, lady, you’re the one who is mistaken.
"Then he pulls out his own key and opens the door. The car did belong to him. By this time, a crowd of people had gathered. I half expected the children to start howling at me, or throwing sticks.
"And then last week, on the way to the hospital, I got lost, Dr. Fleming. I have driven an automobile in this city for over thirty-five years and I got lost. I was out in the suburbs before I got my bearings. I was an hour late for my appointment."
As Mrs. Abrams spoke, Fleming scanned the lines in iambic pentameter written in the nuclear medicine report in the patient’s medical record. These lines spoke to him of the fixed capacity of the human skull, which can contain no more than a fixed quantity of brain, blood, and malignant disease. Fleming realized that Mrs. Abrams had not yet been told that her cancer had metastasized to her brain.
Following protocol, Fleming elicited the rest of the patient’s history. As they were talking, the remembrance of things past seemed to strike an emotional chord. As she dabbed tears from her eyes, Mrs. Abrams suddenly emitted a totally inappropriate and horridly morbid laugh, which bellowed out of the hollows of her chest. The gesture was so abrupt and unexpected, Fleming was taken aback with a start.
Mrs. Abrams strange cachinnation spilled out of her gentle mouth and spread across the bed in Fleming’s direction as a gelatinous wave retarded only by its own intrinsic elasticity. He felt her strange and gruesome laughter stretching out to engulf him, before it receded—spent—into a cry, a sob, the yellow sheaf of bundled tears she tucked beneath her breast.
"I was a mother, Dr. Fleming!" said Isabel Abrams, with emotion. "The mother of fine children."
Stat Call: Corridor O, Room 293, Bed 3
Martin St John had pushed his call button shortly after the onset of dull, agonizing pain beneath his breastbone. The pain now coursed upward into his jaw and neck. The intensity was nearly intolerable. By the time Fleming arrived, Mr. St John's affliction had become overwhelming. His skin was ashen gray. His breathing was labored, his distress unrelieved by the hissing flow of oxygen now rushing through his nostrils.
Fleming assessed the situation quickly. The patient had no measurable blood pressure. His pulse was weak and thready. There were signs of congestive heart failure.
A cascade of possibilities raced through Fleming's mind. The infusion system appeared to be intact. This eliminated the possibility of an air embolus. There were no signs of tamponade of the heart. The pulses, though weak, were equal on each side of the body, ruling out a dissecting aneurysm. A massive pulmonary embolism could not be excluded, but Fleming could detect no evidence of acute strain on the right side of the heart. The most plausible diagnosis was an acute myocardial infarction, a massive heart attack. But why should that have happened?
The EKG machine, which had been connected by the afternoon shift LPN was just now disgorging a tracing that confirmed destruction of almost the entire anterior wall of Martin St John's heart. The patient would have to be transferred immediately to the Coronary Care Unit on the third floor. Fleming started a keep open IV and ordered a sixth of a grain of morphine for the patient's pain.
When all was in readiness, the cortege moved slowly out of Room 293 and down the hallway to the elevator. Fleming and the R.N. from the CCU were monitoring the patient's vital signs. The attendants manipulated the IV poles and the portable oxygen tank.
The group was in the elevator when Martin St John's heart stopped beating. Cardiopulmonary resuscitation was difficult to perform in the tightly enclosed space of the elevator. Despite a valiant effort to revive him, Martin St. John was dead before the elevator reached the third floor.
"We must have an autopsy, Mrs. St John. I can't tell you how crucial this is in your husband's case," Fleming pleaded, when the patient's wife arrived.
The post would uncover the strange circumstances of Martin St John's demise. The catheter in his hepatic artery had dislodged. The tip had snaked up the aorta and had wedged into the left coronary artery. Mechanical obstruction of the vessel by the catheter, together with perfusion of the heart with 5FU-dr, had cut off the supply of oxygenated blood to the heart. Martin St John's death had been the result of a bizarre twist of fate, an accident. In the interest of medical science, the patient's wife and two children would forgive the oncology service.
Fleming was stretched out on the couch in the lab, sipping his tenth cup of coffee of the day. He was waiting for Maurice Dubois to join him so they could make a last revision in the Angell Center patient list. Fleming felt shaky. The sensation was a combination, he surmised, of the effects of the caffeine, the fact he had missed dinner, and residual anxiety about his recent close brush with disaster. Fleming had nearly killed the last patient he had admitted to the service.
The individual had called Fleming complaining of gradually increasing shortness of breath over the past 48 hours. The patient had advanced lung cancer. After examining him on Angell Center, Fleming had obtained a chest X-ray, which confirmed his suspicion of a left sided pleural effusion. The patient had been admitted for thoracentesis and chest tube drainage.
In retrospect, Fleming could only attribute what had nearly happened to fatigue. The day had been long and grueling. The realization that he was prepping the right side of the chest had hit Fleming like a thunderbolt. Fortunately, the patient had innocently asked why it was necessary to sterilize the right side of his chest when it was his understanding the fluid was on the left.
Fleming had come with seconds of placing the catheter into the normal right lung. Had the patient's right lung collapsed, the compromise to air exchange--given the effusion on the left--could have been fatal. In response the patient's inquiry, Fleming had proffered the lame excuse that a wide prep was necessary to avoid infection. He had nonchalantly extended the prep to the left, but he felt like an imbecile.
Mistakes did happen. Fleming had had a few close calls in the past. But this incident had been the most flagrant near miss of his career. Whenever he allowed his mind to wander among the potential consequences of what he had almost done, Fleming became nauseated. He knew he was going to be questioned about the extent of the prep by Dr. Michailovich on Monday. The indelible stain of Mercurochrome he had painted on the patient's skin was a clear indication of his stupidity.
The only rational explanation for the near mistake was fatigue.
Fleming sat up and stretched languorously, emitting a yawn. He picked up a copy of Cancer, looked at it blankly, and then tossed the journal aside. He reached into the pocket of his white coat and removed his copy of the updated list. He sat peering intently at the inventory of names and faces.
Ira Goldstein's portable chest X-ray had confirmed Fleming's suspicion of pneumonia. Mr Goldstein appeared to be responding to antibiotics. The short-term prognosis was excellent.
The new admissions had included Isabel Abrams and Fleming's near disaster. Maurice had admitted another patient to South Pavilion, but Fleming didn't have the name yet.
Fleming had also admitted Francis Heller's patient, Susie Vincent. Susie was a 16 year-old who had osteogenic sarcoma. She had injured her right leg playing basketball during a physical education class in school. When the pain had persisted longer than expected, X-rays had been done. At that point, the sarcoma had been discovered. Susie's right leg had been amputated above the knee.
Dr. Heller had decided to treat her postoperatively with chemotherapy as a precaution, but the tumor had recently spread into her lungs. Susie explained to Fleming that she had been admitted for new medication. As he stared at her name on the list, Fleming recalled Susie's lustrous blue eyes and the scraggly remains of her hair.
"Do you think I'll get any better?" she had asked him.
Fleming had responded appropriately.
The service had lost five patients so far. One had been the elective discharge, Marcus Letterman. Matthew O'Brian, Karen McCaffrey, and Martin St John had expired.
Mr. St John's autopsy had been scheduled for early Sunday morning. Mrs. McCaffrey's post had been completed. The cause of her death had been a large saddle embolus to the main pulmonary artery.
The fifth deletion from the list had been Bill Margolis, in Room 496. Maurice Dubois had paged Fleming to the X-ray department to review Bill's chest films around two o'clock. The black hue of normal air containing lung had been effaced by the white shadows of the patient's awesome disease. Bill Margolis had insufficient lung remaining to oxygenate his blood. Severe hypoxia had caused delirium. Bill had become irrational and refused to remain in bed. The nurse's could not stop him from chewing frantically on his oxygen hose. He had developed a terminal state of the blues.
Bill Margolis had been too young and too strong to control without restraints and sedation. He had died at about 3:30 that afternoon. His family had refused to consent for an autopsy.
Maurice Dubois entered the lab and collapsed into the chair at his desk. He sat for several moments quietly observing Fleming. Dr. Dubois' hands were clasped together. He sat nodding his head very slowly, while rhythmically touching his conjoined index fingers to his lips.
"You look tired, Jackson," he finally said. "Why don't you sign out to me and go home and get some sleep. I'll finish up the paperwork"
Fleming might have protested in order to impress Maurice with his dedication, but the offer was too tempting to refuse. Dr. Dubois could have the honor of being the last of the oncology staff to leave the hospital that evening.
Fleming was sitting in an easy chair in the living room of his apartment. Although he was trying hard to unwind, he was decidedly restless. He was holding an unopened medical journal loosely in his hand.
Fleming took a sip from the bottle of Heineken that was standing on the table next to his chair. He leaned over and switched off the light. He sat in the darkness looking out at the lights of the city through the floor to ceiling windows in the north wall of the room.
Taking his beer with him, Fleming ambled over to the window and stood looking down at the headlights coursing through the streets fifteen stories below. He followed the odyssey of a flashing red light as an ambulance streaked through the intersections.
Fleming lived unostentatiously. His apartment reflected meticulous neatness and order. The room contained a sofa, a couple of side tables, and the easy chair. One wall was lined with bookcases, filled with a tedious array of medical textbooks and journals. A few non-medical volumes were stacked inconspicuously on a bottom shelf. Among these, were Mort Thompson's Not As a Stranger, Look Homeward Angel, a dog-eared copy of Wuthering Heights, and the Random House edition of Ulysses. A four volume boxed set of The Greek Plays appeared not to have been opened.
No paintings or decorative artifacts embellished the space Fleming lived in. The theme of the entire apartment was simplistic function.
Fleming returned to the chair. He decided to call Alice Cassidy. Ordinarily, he would not have considered calling on a Saturday evening, but he knew Alice was not a creature of habit and that she might be free. The two of them had agreed early on not to stand on protocol. Unsolicited telephone calls would be accepted or not, as the circumstances warranted.
Flicking the lamp back on, Fleming dialed Alice's number. The phone rang a few times before she answered.
"Hello, Alice, this is Jack."
"Jack! This is a pleasant surprise. I never expected to hear from you tonight. Aren't you working this weekend?"
"Can you talk, Alice?"
"Sure, Jack. I'm here all by myself repotting an azalea. Some Saturday night, don't you think?"
"Look, Alice, I know it's late, but I was wondering if we could get together for awhile?"
"Hey, Jack," she said, evincing concern, "Are you alright? You sound a little down."
"No, no, Alice, I'm fine, really. I just got off work. I guess I'm just feeling a little lonely."
"Well, in that case, why don't you come on over. I was feeling a little lonely myself."
"You're sure you don't mind?"
"No, silly, I'd love to see you."
"Then I'll be there in a few minutes."
"Will you be staying the night, Jack?"
"Well, I was thinking. I do have to be back to work early tomorrow. It would be easier."
"Well, why don't you plan to stay with me then."
"OK, that sounds great. And, Alice?"
"Thanks. Thanks a lot."
Alice Cassidy's Apartment
Fleming had met Alice Cassidy at one of the parties he occasionally attended. They had hit it off well from the beginning. He had come on to Alice with a wild hype about how he was a Transylvanian physician on a worldwide mission to restore the reputation of werewolves. With a straight face, he had explained that werewolves were not monsters, but the victims of a rare disease called porphyria cutanea tarda. The salient features of the disease are hirsutism, photophobia, and mental aberrations. Hence the hairy lupine appearance, the nocturnal prowling in the subdued light of the moon, and the wild behavior. Down the centuries, legend had unfairly stigmatized the victims of PCT and created the werewolf myth.
Alice had remarked, with a good-natured laugh, that anyone with a line like that might have possibilities. Alice Cassidy and Jack Fleming began to see one another.
Alice Cassidy was older than Fleming. He knew very little about her, really, other than her employment as an interior decorator and the fact that she lived alone. Otherwise, Alice chose not to tell him much about her life. She intimated that there had been an early marriage, but like Katherine of Aragon, she had been cast off for a younger woman because of her failure to produce an heir. Alice told this to Fleming one evening in a café when she had consumed more wine than usual. Fleming had never been able to decide whether the story was true.
Alice Cassidy thrived on sensations. She lived her life with unusual gusto. She refused to intellectualize her existence, casting off philosophical ruminations as inane and of no lasting value. Good food, music, art, and sex ranked equally among Alice's priorities. On the intricate stage that comprised Alice Cassidy's life, the footlights never grew dim.
"I'll never fall in love with you, Jack," Alice had informed him at the beginning of their friendship. "At least, not in any conventional sense of that word. Don't ever do me the dishonor of falling in love with me."
Fleming found it convenient not to question Alice's position or the emotional restrictions she insisted upon. She seemed to enjoy being there for him. She tolerated his rambling discourses about his all-consuming aspirations in medicine. She left him little doubt that she intensely relished his companionship. From Fleming's perspective, Alice Cassidy had been an incredibly fortuitous find. Their involvement eliminated any pressure toward commitment that a more conventional relationship might have engendered. Alice provided him a convenient outlet for his emotional and physical needs with no strings attached. The relationship had lasted nearly two years, far longer than either of them had expected in the beginning.
On a couple of occasions, Alice Cassidy and Jack Fleming had lived together for short periods. In each instance, they had sensed simultaneously that an amicable termination of their cohabitation was necessary. Invariably, after a short hiatus, one or the other made overtures to renew the relationship.
Fleming let himself into Alice Cassidy's apartment. The two had agreed to exchange keys. The arrangement had lent some stability to the relationship without threatening the independence they both valued so highly, at least so far.
"That you, Jack?" Alice called out from the bedroom. "Grab a beer, will you? I'll be right out."
After extracting a Heineken from the refrigerator in the kitchen nook, Fleming walked back into Alice's living room. The space exuded a warm sense of being lived in with abandon. Pillows, all carefully coordinated, were scattered about the couch and floor. Plants, in pots or hangers, were integrated unobtrusively with various objets d' art. Prints, custom framed and fine, adorned the walls in a unifying theme. Alice had a penchant for Impressionism.
Before the fireplace stood a low oriental table. Around this, Alice had arranged sets of pillows. A large scented candle and several incense holders stood on the lacquered tabletop. The dining room table was covered with newsprint spattered with mounds of potting soil and gravel. In the midst of the debris sat a freshly potted azalea with variegated leaves of violet and gold.
"There you are, my welcome young man," Alice said cheerfully, as she entered the room. "I'm so glad you could come over."
Fleming placed his beer on the countertop and embraced her warmly.
Alice Cassidy was a sensuously attractive woman. She was dark complected and small in stature. Her vivacious energy was contagious. She was dressed in her favorite attire, close fitting slacks and a shirt worn open at the neck, exposing the cleavage of her relatively large breasts. Alice reminded Fleming of the actress, Anna Magnani.
"Come sit with me awhile," she said, leading Fleming over to the couch. "You must explain what's bothering you. And don't tell me nothing is. I know you too well for that."
They sat together on the couch. Alice was sitting sideways, facing Fleming. Her legs were tucked beneath her and she had clasped a pillow to her chest. Fleming sat frontally, staring at the bottle of Heineken in his hands and toying with the paper label.
"I really don't know what's bothering me, Alice," he said. His face displayed a troubled expression.
"I experienced a host of things today that should be bothering me a lot, but I don't seem to be reacting to any of them. The only emotions I actually felt today were rage at a dying priest and panic when I almost killed a guy. I feel so damned superficial sometimes. Nothing seems to get to me unless it affects me personally."
"Come on, Jack, don't be silly," Alice said. "People like me are superficial. You're going to be an oncologist, your life has direction. As far as those poor people you deal with, how could you possibly react to all of them? Doing so would destroy you."
Fleming began to peel away the label from the bottle of Heineken.
"I don't know, Alice," he said finally. "There are so many aspects of life I haven't thought about for a long time."
"Maybe existence is a lot easier if we don't think about it at all," Alice suggested. "Now come over here."
Alice stretched out on the couch and pulled Fleming down beside her.
He nestled his face into Alice's neck. She held him close, stroking his head gently. She could sense his immediate arousal. They toyed with one another during a crescendo of rising excitement.
"Get high with me, Jack," Alice whispered into Fleming's ear. "You really need to relax a little."
"Come on, Alice," Fleming said emphatically. "You know I don't want to mess around with that stuff."
"OK, silly," she said, as she rose to her feet and walked in the direction of the bedroom. "But you don't know what you're missing."
They sat on the bed while Alice hit up on the grass.
"Get undressed for me, Jack," she said seductively. Wisps of grayish smoke swirled before the heavy lids of her eyes.
As he disrobed, Fleming felt the thrill of submission. He was trembling with the rush of his arousal as Alice moved into position beneath him. He playfully forced her down onto the surface of the bed and lifted her thighs until they were pressing against her breasts. Overcoming Alice's mock resistance, Fleming buried himself in the warm softness of her flesh.
"Oh yes, Jack, I'm coming!" Alice crooned a few moments later.
They had settled into a sweaty pounding rhythm.
"Oh, God Damn you, I'm coming so hard."