One

“There was one new admission last night,” said Cassandra Kingsley, glancing down at her preliminary work-up. She felt distinctly ill at ease, having been thrust into the spotlight of the early morning team meeting on the psychiatry ward, Clarkson Two. “His name is Colonel William Bentworth. He’s a forty-eight-year-old Caucasian male, thrice divorced, who’d been admitted through the ER after an altercation in a gay bar. He was acutely intoxicated and abusive to the ER personnel.”

“My God!” laughed Jacob Levine, the chief psychiatric resident. He took off his round, wire-rimmed glasses and rubbed his eyes. “Your first night on psychiatry call and you get Bentworth!”

“Trial by fire,” said Roxane Jefferson, the black, no-nonsense head nurse for Clarkson Two. “No one can say psychiatry at the Boston Memorial is a boring rotation.”

“He wasn’t my idea of a perfect patient,” admitted Cassi with a weak smile. Jacob’s and Roxane’s comments made her feel a bit more relaxed, sensing that if she made an ass of herself with her presentation, everyone would excuse her. Bentworth was no foreigner to Clarkson Two.

Cassi had been a psychiatry resident for less than a week. November wasn’t the usual time for people to begin a residency, but Cassi had not decided to switch from pathology to psychiatry until after the beginning of the medical year in July and had only been able to do so because one of the first-year residents had quit. At the time Cassi thought she’d been extraordinarily lucky. But now she wasn’t so sure. Starting a residency without other colleagues equally as inexperienced was more difficult than she’d anticipated. The other first-year residents had almost a five-month jump on her.

“I bet Bentworth had some choice words for you when you showed up,” sympathized Joan Widiker, a third-year resident who was currently running the psychiatric consultation service and who had taken an immediate liking to Cassi.

“I wouldn’t want to repeat them,” admitted Cassi, nodding toward Joan. “In fact he refused to talk with me at all, other than to tell me what he thought of psychiatry and psychiatrists. He did ask for a cigarette, which I gave him, thinking it might relax him, but instead of smoking it he proceeded to press the lighted end against his arms. Before I could get some help, he’d burned himself in six places.”

“He’s a charmer all right,” said Jacob. “Cassi, you should have called me. What time did he come in?”

“Two-thirty A.M.,” said Cassi.

“I take that back,” said Jacob. “You did the right thing.”

Everyone laughed, including Cassi. For once there wasn’t that substratum of hostile competition that had colored all her years of training. And none of the half-respectful, half-jealous commentary that had surrounded her relations at Boston Memorial since her marriage to Thomas Kingsley. Cassi hoped she would be able to repay their support.

“Anyway,” she said, trying to organize her thoughts. “Mr. Bentworth, or I should say Colonel Bentworth, U.S. Army, presented with acute alcohol intoxication, diffuse anxiety alternating with a depressionlike state, fulminating anger, self-mutilating behavior, and an eight-pound chart of his previous hospitalizations.”

The group erupted with renewed laughter.

“One point to Colonel Bentworth’s credit,” said Jacob, “is that he has helped train a generation of psychiatrists.”

“I had that feeling,” admitted Cassi. “I tried to read the most important parts of the chart. I think it’s about the same length as War and Peace. At least it kept me from making a fool of myself and hazarding a diagnosis. He’s been classified as a borderline personality disorder with occasional brief psychotic states.

“On physical examination he had multiple contusions on his face and a small laceration of his upper lip. The rest of the physical examination was normal except for his recent self-inflicted burns. There were slight scars across both wrists. He refused to cooperate for a full neurological exam, but he was oriented to time, place, and person. Since the present admission mirrored the last admission in terms of symptoms and since amytal sodium was used on the previous admission with such success, half a gram was given slowly IV.”

At almost the exact instant that Cassi finished her presentation, her name floated out of the hospital page system. By reflex she started to get up, but Joan restrained her, saying the ward clerk would answer.

“Did you think Colonel Bentworth was a suicide risk?” asked Jacob.

“Not really,” said Cassi, knowing she was hedging. Cassi was well aware that her ability to estimate suicide risk was approximately the same as the man in the street’s. “Burning himself with his cigarette was self-mutilating rather than self-destructive.”

Jacob twirled a lock of his frizzed hair and glanced at Roxane, who had been on Clarkson Two longer than anyone else. She was recognized as an authority of sorts. That was another reason why Cassi enjoyed the psychiatry service. There wasn’t the stiff structure that existed elsewhere in the hospital, with physicians implacably at the top. Doctors, nurses, aides, everyone was part of the Clarkson Two team and respected as such.

“I’ve tended to ignore the distinction,” said Roxane, “but I suppose there is a difference. Still we should be careful. He’s an extremely complex man.”

“That’s an understatement,” said Jacob. “The guy had a meteoric rise in the military, especially during his multiple tours of duty in Vietnam. He was even decorated several times, but when I looked into his army record, it always seemed as if a disproportionate number of his own men were killed. His psychiatric problems didn’t seem to show up until he’d reached his present rank of colonel. It was as if success destroyed him.”

“Getting back to the risk of suicide,” said Roxane, turning to Cassi. “I think the degree of depression is the most important point.”

“It wasn’t typical depression,” said Cassi, knowing she was venturing out on thin ice. “He said he felt empty rather than sad. One minute he acted depressed and the next he’d erupt with anger and abusive language. He was inconsistent.”

“There you go,” said Jacob. It was one of his favorite phrases, and its meaning was related to how he stressed the words. In this instance he was pleased. “If you had to pick one word to characterize a borderline patient, I think ‘inconsistency’ would be the most appropriate.”

Cassi happily absorbed the praise. Her own ego had had very little to feed on during the previous week.

“Well, then,” said Jacob. “What are your plans for Colonel Bentworth?”

Cassi’s euphoria vanished.

Then one of the residents said, “I think Cassi should get him to stop smoking.”

The group laughed and her tension evaporated.

“My plans for Colonel Bentworth,” said Cassi, “are . . .” she paused, “that I’m going to have to do a lot of reading over the weekend.”

“Fair enough,” said Jacob. “In the meantime I’d recommend a short course of a major tranquilizer. Borderlines don’t do well on extended medication, but it can help them over transient psychotic states. Now then, what else happened last night?”

Susan Cheaver, one of the psychiatric nurses, took over. With her usual efficiency, Susan summarized all the significant events that had taken place since late afternoon the previous day. The only happening out of the ordinary was an episode of physical abuse suffered by a patient called Maureen Kavenaugh. Her husband had come for one of his infrequent visits. The meeting had seemingly gone well for a while, but then there were angry words followed by a series of vicious openhanded slaps by Mr. Kavenaugh. The episode occurred in the middle of the patient lounge and severely upset the other patients. Mr. Kavenaugh had to be subdued and escorted from the ward. His wife had been sedated.

“I’ve spoken with the husband on several occasions,” said Roxane. “He’s a truck driver with little or no understanding of his wife’s condition.”

“And what do you suggest?” asked Jacob.

“I think,” said Roxane, “that Mr. Kavenaugh should be encouraged to visit his wife but only when someone can be with them. I don’t think Maureen will be able to retain a remission unless he’s brought into the therapy in some capacity, and I think it’s going to be hard to get him to cooperate.”

Cassi watched and listened as the whole psychiatric team participated. After Susan had finished, each of the residents had an opportunity to discuss their patients. Then the occupational therapist, followed by the psych social worker, had a chance to speak. Finally Dr. Levine asked if there were any other problems. No one moved.

“Okay,” said Dr. Levine, “see you all at afternoon rounds.”

Cassi did not get up immediately. She closed her eyes and took a deep breath. The anxiousness engendered by the team meeting had hidden her exhaustion, but now that the excitement was over she felt it with a vengeance. She’d had only three hours of sleep. And for Cassi rest was important. Oh, how nice it would have felt to just lay her head down on her arm right there on the conference table.

“I bet you’re tired,” said Joan Widiker, placing her hand on Cassi’s arm. It was a warm, reassuring gesture.

Cassi managed a smile. Joan was genuinely interested in other people. More than anyone, she had taken time to make Cassi’s first week as a psychiatry resident as easy as possible.

“I’ll make it,” said Cassi. Then she added: “I hope.”

“You’ll make it fine,” assured Joan. “In fact you did marvelously this morning.”

“Do you really think so?” asked Cassi. Her hazel eyes brightened.

“Absolutely,” said Joan. “You even drew a compliment of sorts out of Jacob. He liked your description of Colonel Bentworth as inconsistent.”

“Don’t remind me,” said Cassi forlornly. “The truth is I wouldn’t know a borderline personality disorder if I met one at dinner.”

“You probably wouldn’t,” agreed Joan. “Nor would many other people, provided the patient was not having a psychotic episode. Borderlines can be fairly well compensated. Look at Bentworth. He’s a colonel in the army.”

“That did bother me,” said Cassi. “It didn’t seem to be consistent, either.”

“Bentworth can upset anyone,” said Joan, giving Cassi’s arm a supportive squeeze. “Come on. I’ll buy you some coffee in the coffee shop. You look like you could use it.”

“I can use it all right,” agreed Cassi. “But I’m not sure I should take the time.”

“Doctor’s orders,” said Joan, getting up. As they walked down the corridor, she added, “I got Bentworth when I was a first-year resident, and I had the same experience as you did. So I know how you feel.”

“No kidding,” said Cassi, encouraged. “I didn’t want to admit it at the meeting, but I found the colonel frightening.”

Joan nodded. “Look, Bentworth’s trouble. He’s vicious, and he’s smart. Somehow he knows just how to get at people: find their weaknesses. That power, combined with his pent-up anger and hostility, can be devastating.”

“He made me feel completely worthless,” said Cassi.

“As a psychiatrist,” corrected Joan.

“As a psychiatrist,” agreed Cassi. “But that’s what I’m supposed to be. Maybe if I could find some similar case histories to read.”

“There is plenty of literature,” said Joan. “Too much. But it’s a little like learning to ride a bike. You could read everything about bicycles, for years, yet when you finally tried to ride it yourself, you wouldn’t be able to. Psychiatry is as much a process as it is knowledge. Come on, let’s get that coffee.”

Cassi hesitated. “Maybe I should get to work.”

“You don’t have any scheduled patient meetings right now, do you?” asked Joan.

“No, but . . .”

“Then you’re coming.” Joan took her arm and they started walking again.

Cassi allowed herself to be led. She wanted to spend a little time with Joan. It was encouraging as well as instructive. Maybe Bentworth would be willing to talk after a night’s rest.

“Let me tell you something about Bentworth,” said Joan, as if reading Cassi’s mind. “Everyone that I know who has taken care of him, myself included, was certain they would cure him. But borderlines in general and Colonel Bentworth in particular don’t get cured. They can get progressively better compensated but not cured.”

As they passed the nurses’ station, Cassi left Bentworth’s chart and asked about her page. “It was Dr. Robert Seibert,” said the aide. “He asked for you to call as soon as possible.”

“Who’s Dr. Seibert?” asked Joan.

“He’s a resident in pathology,” answered Cassi.

“As soon as possible sounds like you’d better call,” said Joan.

“Do you mind?”

Joan shook her head, and Cassi went around the counter to use the phone next to the chart rack. Roxane came over to Joan. “She’s a nice kid,” the nurse said. “I think she’s going to be a real addition around here.” Joan nodded, and they both agreed that Cassi’s insecurity and anxiety were a function of her commitment and dedication.

“But she worries me a little,” added Roxane. “She seems to have a special vulnerability.”

“I think she’ll be fine,” said Joan. “And she can’t be too weak being married to Thomas Kingsley.”

Roxane grinned and walked down the hall. She was a tall, elegant black woman who commanded respect for her intellect and sense of style. She’d worn her hair braided in corn rows long before it was fashionable.

As Cassi put down the phone, Joan eyed her carefully. Roxane was right. Cassi did seem delicate. Perhaps it was her pale, almost translucent skin. She was slender but graceful, only slightly over five-feet-two. Her hair was fine and varied in color from a shiny walnut to blond depending upon the angle and the light. At work she wore it loosely piled on her head, held in place with small combs and hairpins. But because of its texture, wisps spilled down around her face in gossamer strands. Her features were small and narrow, and her eyes turned up ever so slightly at the outer corners, giving them a mildly exotic appearance. She wore little makeup, which made her look younger than her twenty-eight years. Her clothes were always neat even if she’d been up most of the night, and today she was dressed in one of her many high-necked white blouses. To Joan, Cassi appeared like a young woman in an old Victorian photograph.

“Instead of going for coffee,” said Cassi with enthusiasm, “how about coming with me to pathology for a few minutes?”

“Pathology,” said Joan, with some reluctance.

“I’m sure we can get coffee up there,” said Cassi, as if that was the explanation of Joan’s hesitation. “Come on. You might find it interesting.”

Joan allowed herself to be led down the main corridor to the heavy fire door which led into the hospital proper. There were no locked doors on Clarkson Two. It was an “open” ward. Many of the patients were not allowed to leave the floor, but compliance was up to them. They knew if they ignored the rules they risked being sent to the State Hospital. There the environment was significantly different and much less pleasant.

As the door closed behind her, Cassi felt a sense of relief. In sharp contrast to the psychiatry ward, here in the main hospital building it was easy to distinguish the doctors and nurses from the patients. The doctors wore either suit jackets or their white coats; the nurses, their white uniforms; and the patients, their hospital johnnies. Back in Clarkson Two everyone wore street clothes.

As Cassi and Joan threaded their way toward the central elevators, Joan asked, “What was it like being a resident in pathology? Did you like it?”

“I loved it,” said Cassi.

“I hope you don’t take this as an insult,” laughed Joan. “But you don’t look like any pathologist I know.”

“It’s the story of my life,” said Cassi. “First nobody would believe I was a medical student, then they said I looked too young to be a doctor, and last night Colonel Bentworth was kind enough to tell me I didn’t look like a psychiatrist. What do you think I look like?”

Joan didn’t answer. The truth was Cassi looked more like a dancer or a model than a doctor.

They joined the crowd of people in front of the bank of elevators serving Scherington, the main hospital building. There were only six elevators, which turned out to be an architectural blunder. Sometimes you could wait ten minutes for a car and then have to stop at every floor.

“What made you switch residencies?” asked Joan. As soon as the question left her lips, she regretted it. “You don’t have to answer that. I don’t mean to pry. I guess it’s the psychiatrist in me.”

“It’s quite all right,” said Cassi equably. “And actually it’s quite simple. I have juvenile diabetes. In choosing my medical specialty, I’ve had to keep that reality in mind. I’ve tried to ignore it, but it is a definite handicap.”

Joan’s embarrassment was increased by Cassi’s candor. Yet as uncomfortable as Joan felt, she thought it would be worse not to respond to Cassi’s honesty. “I would have thought under the circumstances pathology would have been a good choice.”

“I thought so too, at first,” said Cassi. “But unfortunately during the past year I began to have trouble with my eyes. In fact, at the moment I can only distinguish light and dark with my left eye. I’m sure you know all about diabetic retinopathy. I’m not a defeatist but if worse comes to worst, I could practice psychiatry even if I became blind. Not so with pathology. Come on, let’s get that first elevator.”

Cassi and Joan were swept into the car. The door closed, and they started up.

Joan had not felt so uncomfortable in years, but she felt she had to respond. “How long have you had diabetes?” she asked.

The simple question hurled Cassi back in time. Back to when she was eight and her life began to change. Up to that point, Cassi had always liked school. She was an eager, enthusiastic child who seemed to look forward to new experiences. But in the middle of the third grade it all changed. In the past she’d always been ready for school early; now she had to be pushed and cajoled by her mother. Her concentration dwindled and notes to that effect began to arrive from her teacher. One of the central issues, something that no one recognized, not even Cassi herself, was that Cassi had to use the girls’ room more and more frequently. After a time the teacher, Miss Rossi, began on occasion to refuse Cassi’s requests, suspecting that she was using trips to the toilet to avoid her work. When this happened, Cassi experienced the awful fear that she would lose control of her bladder. In her mind’s eye she could picture what it would look like if she had “an accident,” and her urine dripped down from her seat and puddled under her desk. The fear brought on anger and the anger, ostracism. The kids began to make fun of Cassi.

At home an episode of bedwetting surprised and shocked both Cassandra and her mother. Mrs. Cassidy demanded an explanation, but Cassandra had none and was, in fact, equally appalled. When Mr. Cassidy suggested they consult the family doctor, Mrs. Cassidy was too mortified to do so, convinced as she was that the whole affair was a behavioral disorder.

Various punishments had no effect. If anything they exacerbated the problem. Cassi began to throw temper tantrums, lost her few remaining friends, and spent most of her time in her room. Mrs. Cassidy reluctantly began to think about the need for a child psychologist.

Things came to a head in the early spring. Cassi could remember the day vividly. Only a half hour after a recess, she began to experience a combination of mounting bladder pressure and thirst. Anticipating Miss Rossi’s response so close to recess, Cassi tried vainly to wait for class to end. She squirmed in her seat and clutched her hands into tight fists. Her mouth became so dry she could barely swallow, and despite all her efforts, she felt the release of a small amount of urine.

In terror she walked pigeon-toed up to Miss Rossi and asked to be excused. Miss Rossi, without a glance, told her to take her seat. Cassi turned and walked deliberately to the door. Miss Rossi heard it open and looked up.

Cassi fled to the he girls’ room with Miss Rossi at her heels. She had her panties down and her dress bunched in her arms before Miss Rossi caught up to her. With relief, the little girl sank onto the toilet. Miss Rossi stood her ground, putting her hands on her hips, and waited with an expression that said: “You’d better produce or else . . .”

Cassi produced. She began to urinate and continued for what seemed like an incredible duration of time. Miss Rossi’s angry expression mellowed. “Why didn’t you go during recess?” she demanded. “I did,” said Cassi plaintively.

“I don’t believe you,” said Miss Rossi. “I just don’t believe you, and this afternoon after school, we are going to march down to Mr. Jankowski’s office.”

Back in the classroom, Miss Rossi made Cassi sit by herself. She could still remember the dizziness that came over her. First she couldn’t see the blackboard. Then she felt strange all over and thought she was going to vomit. But she didn’t. Instead she passed out. The next thing Cassi knew was that she was in the hospital. Her mother was bending over her. She told Cassi she had diabetes.

Cassi turned to Joan, bringing her mind back to the present.

“I was hospitalized when I was nine,” said Cassi hurriedly, hoping Joan hadn’t noticed the fact that she had been daydreaming. “The diagnosis was made then.”

“That must have been a difficult time for you,” said Joan.

“It wasn’t so bad,” said Cassi. “In some respects it was a relief to know that the symptoms I had been having had a physical basis. And once the doctors stabilized my insulin requirements, I felt much better. By the time I reached my teens I even got used to giving myself the injections twice a day. Ah, here we are.” Cassi motioned them off the elevator.

“I’m impressed,” said Joan with sincerity. “I doubt if I’d have been able to handle my medical training if I had had diabetes.”

“I’m certain you would have,” said Cassi casually. “We’re all more adaptable than we give ourselves credit for.”

Joan wasn’t sure she agreed, but she let it go. “What about your husband? Having known a few surgeons in my life, I hope he’s understanding and supportive.”

“Oh, he is,” said Cassi, but she answered too quickly for Joan’s analytical mind.

Pathology was its own world, completely separate from the rest of the hospital. As a psychiatric resident, Joan hadn’t visited the floor in the two years she’d been at Boston Memorial. She had prepared herself for the dark, nineteenth-century appearance of the department of pathology in her medical school, complete with dingy glass-fronted cabinets filled with round specimen jars containing bits of horror in yellowing Formalin. Instead, she found herself in a white, futuristic world composed of tile, Formica, stainless steel, and glass. There were no specimens and no clutter and no strangely repulsive smells. At the entrance there were a number of secretaries with earphones typing onto word-processing screens. To the left were offices, and down the center was a long white Formica table supporting double-headed microscopes.

Cassi led Joan into the first office where an impeccably dressed young man leaped up from his desk and greeted Cassi with a big, unprofessional hug. Then the man thrust Cassi away so he could look at her.

“God, you look good,” he said. “But wait. You haven’t colored your hair, have you?”

“I knew you’d notice,” laughed Cassi. “No one else has.”

“Of course I’d notice. And this is a new blouse. Lord and Taylor?”

“No, Saks.”

“It’s wonderful.” He fingered the material. “It’s all cotton. Very nice.”

“Oh, I’m sorry!” said Cassi, remembering Joan and introducing her. “Joan Widiker, Robert Seibert, second-year pathology resident.”

Joan took Robert’s outstretched hand. She liked his engaging, forthright smile. His eyes twinkled, and Joan had the feeling she’d been instantly inspected.

“Robert and I went to the same medical school,” explained Cassi as Robert put his arm around her again. “And then by chance we both ended up here at the Boston Memorial for first-year pathology.”

“You two look like you could be brother and sister,” said Joan.

“People have said that,” said Robert, obviously pleased. “We had an immediate affinity for each other for a lot of reasons including the fact that we both had serious childhood diseases. Cassi had diabetes, and I had rheumatic fever.”

“And we’re both terrified of surgery,” said Cassi, causing herself and Robert to burst out laughing.

Joan assumed it was some kind of private joke.

“Actually, it’s not so funny,” said Cassi. “Instead of mutually supporting each other, we’ve ended up making each other more scared. Robert is supposed to have his wisdom teeth removed, and I’m supposed to have the hemorrhage in my left eye cleared.”

“I’m going to have mine taken care of soon,” said Robert defiantly. “Now that I’ve got you out of my hair.”

“I’ll believe that when it happens,” laughed Cassi.

“You’ll see,” said Robert. “But meanwhile let’s get down to business. I’ve saved the autopsy until you got here. But first I promised to call the medical resident who tried to resuscitate the patient.”

Robert stepped back to his desk and picked up his phone.

“Autopsy!” Joan whispered, alarmed. “I didn’t bargain on an autopsy. I’m not sure I’m up for that.”

“It might be worthwhile,” said Cassi innocently, as if watching an autopsy was something people did for amusement. “During my time as a pathology resident, Robert and I became interested in a series of cases that we’ve labeled SSD, for sudden surgical death. What we found was a group of cardiac surgery patients who had died less than a week after their operations even though most had been doing well and who, on autopsy, had no anatomical cause of death. A few might be understandable, but counting what turned up in the records for the last ten years, we found seventeen. The case Robert is going to autopsy now could make eighteen.”

Robert returned from the phone saying Jerry Donovan would be right down and offered his guests coffee. Before they had a chance to drink it, Jerry arrived on the run. The first thing he did was give Cassi a hug. Joan was impressed. Cassi seemed to be on friendly terms with everyone. Then he slapped Robert on the shoulder and said, “Hey, man, thanks for the call.”

Robert winced at the impact of the blow and forced a smile.

To Joan, Jerry was dressed like the usual house officer. His white jacket, rumpled and soiled, hung askew due to the weight of an overstuffed black notebook in the right pocket. His pants were spotted with a line of bloodstains across the thighs. Next to Robert, Jerry looked like a floor sweeper in a meat-packing house.

“Jerry went to the same medical school as Robert and I,” explained Cassi. “Only he was an upper classman.”

“A distinction that is still painfully obvious,” kidded Jerry.

“Let’s go,” said Robert. “I’ve had one of the autopsy rooms on hold long enough.”

Robert left first, followed by Joan. Jerry stepped aside for Cassi, then caught up to her.

“You’ll never guess who I had the pleasure of watching do his thing last night,” said Jerry as they skirted the microscope table.

“I wouldn’t even try,” said Cassi, expecting some off-color humor.

“Your husband! Dr. Thomas Kingsley.”

“Really?” said Cassi. “What was a medicine man like you doing in the OR?”

“I wasn’t,” said Jerry. “I was on the surgical floor trying to resuscitate the patient we’re going to autopsy. Your husband responded to the code. I was impressed. I don’t think I’ve ever seen such decisiveness. He ripped this guy’s chest open and gave open-heart massage right on the bed. It blew my mind. Tell me, is your husband that impressive at home?”

Cassi shot Jerry a harsh glance. If that comment had come from anybody but Jerry, she probably would have snapped back. But she expected off-color humor and there it was. So why make an issue? She decided to let it drop.

Ignoring Cassi’s less-than-positive reaction, Jerry continued: “The thing that impressed me was not the actual cutting open of the guy’s chest but rather the decision to do it in the first place. It’s so goddamn irreversible. It’s a decision I don’t know how anybody could make. I agonize over whether or not to start a patient on antibiotics.”

“Surgeons get used to that sort of thing,” said Cassi. “That kind of decision making becomes a tonic. In a sense they enjoy it.”

“Enjoy it?” echoed Jerry with disbelief. “That’s pretty hard to believe, but I suppose they must; otherwise we wouldn’t have any surgeons. Maybe the biggest difference between an internist and a surgeon is the ability to make irreversible decisions.”

Entering the autopsy room, Robert donned a black rubber apron and rubber gloves. The others grouped around the pale corpse whose chest still gaped open. The edges of the wound had darkened and dried. Except for an endotracheal tube that stuck rudely out of the mouth, the patient’s face looked serene. The eyes were thankfully closed.

“Ten to one it was a pulmonary embolism,” said Jerry confidently.

“I’ll put a dollar on that,” said Robert, positioning a microphone which hung from the ceiling at a convenient height. It was operated by a foot pedal. “You told me yourself the patient initially had been very cyanotic. I don’t think we’re going to find an embolism. In fact, if my hunch is correct, we’re not going to find anything.”

As Robert began his examination, he started dictating into the mike. “This is a well-developed, well-nourished Caucasian male weighing approximately one hundred sixty-five pounds and measuring seventy inches in length who appears to be of the stated age of forty-two . . .”

As Robert went on to describe the other visible evidence of Bruce Wilkinson’s surgery, Joan stared at Cassi, who was placidly sipping her coffee. Joan looked down at her own cup. The idea of drinking it made her stomach turn.

“Have all these SSD cases been the same?” asked Joan, trying not to look at the table where Robert was arranging scalpels, scissors, and bone clippers in preparation of opening and eviscerating the corpse.

Cassi shook her head. “No. Some have been cyanotic like this case, some seemed to have died from cardiac arrest, some from respiratory failure, and some from convulsions.”

Robert began the usual Y-shaped autopsy incision, starting high on the shoulder and connecting with the open-chest incision. Joan could hear the blade scrape across the underlying bony structures.

“What about the kind of surgery?” asked Joan. She heard ribs crack and closed her eyes.

“They’ve all had open-heart surgery but not necessarily for the same condition. We’ve checked anesthesia, duration of pump time, whether or not hypothermia was used. There were no correlations. That’s been the frustrating part.”

“Well, why are you trying to relate them?”

“That’s a good question,” said Cassi. “It has to do with the mentality of a pathologist. After you’ve done an autopsy, it’s very unsatisfying not to have a definitive cause of death. And when you have a series of such cases, it’s demoralizing. Solving the puzzle is what makes pathology rewarding.”

Involuntarily Joan’s eyes stole a quick glance at the table. Bruce Wilkinson appeared as if he’d been unzipped. The skin and subcutaneous structures of the chest and thorax had been folded back like the leaves of a gigantic book. Joan felt herself swaying.

“The knowledge is important,” Cassi went on, unaware of Joan’s difficulties. “It can have a direct benefit to future patients if some preventable cause is discovered. And in this situation, we’ve noticed an alarming trend. The initial patients seemed to have been older and much sicker. In fact, most were in irreversible coma. Lately though, the patients have been under fifty and generally healthier, like Mr. Wilkinson here. Joan, what’s the matter?” Cassi had turned and finally noticed that her friend seemed about to faint.

“I’m going to wait outside,” said Joan. She turned and started for the door, but Cassi caught her arm.

“Are you all right?” asked Cassi.

“I’ll be fine,” said Joan. “I just need to sit down.” She fled through the stainless steel door.

Cassi was about to follow when Robert called for her to look at something. He pointed at a quarter-sized contusion on the surface of the heart.

“What do you think of that?” asked Robert.

“Probably from the resuscitation attempt,” said Cassi.

“At least we agree on that,” said Robert as he directed his attention back to the respiratory system and the larynx. Deftly he opened the breathing passages. “No obstruction of any sort. If there had been, that would have explained the deep cyanosis.”

Jerry grunted and said, “Goin’ to be pulmonary embolism. I’m sure of it.”

“It’s a bad bet,” said Robert, shaking his head.

Switching his attention lower, Robert examined the main pulmonary vessels and the heart itself. “These are the bypass vessels sewn in place.” He leaned back so Cassi and Jerry could take a look.

Hefting a scalpel, Robert said: “Okay, Dr. Donovan. Better put your money on the table.” Robert bent over and opened the pulmonary arteries. There were no clots. Next he opened the right atrium of the heart. Again the blood was liquid. Finally he turned to the vena cava. There was a bit of tension as the knife slipped into the vessels, but they too were clear. There were no emboli.

“Crap!” said Jerry in disgust.

“That’s ten dollars you owe me,” said Robert smugly.

“What the hell could have bumped this guy off?” asked Jerry.

“I don’t think we’re going to find out,” said Robert. “I think we’ve got number eighteen here.”

“If we are going to find anything,” said Cassi, “it will be inside the head.”

“How do you figure?” asked Jerry.

“If the patient was really cyanotic,” said Cassi, “and we haven’t found a right-to-left circulatory shunt, then the problem has to be in the brain. The patient stopped breathing, but the heart kept pumping unoxygenated blood. Thus cyanosis.”

“What’s that old saying?” said Jerry. “Pathologists know everything and do everything but too late.”

“You forgot the first part,” said Cassi. “Surgeons know nothing but do everything. Internists know everything but do nothing. Then comes the part about pathologists.”

“And what about psychiatrists?” asked Robert.

“That’s easy,” laughed Jerry. “Psychiatrists know nothing and do nothing!”

Quickly Robert finished the autopsy. The brain appeared normal on close examination. No sign of clot or other trauma.

“Well?” asked Jerry, staring at the glistening convolution of Bruce’s brain. “Do you two hotshots have any other bright ideas?”

“Not really,” said Cassi. “Maybe Robert will find evidence of a heart attack.”

“Even if I do,” said Robert, “it wouldn’t explain the cyanosis.”

“That’s true,” said Jerry, as he scratched the side of his head. “Maybe the nurse was wrong. Maybe the guy was just ashen.”

“Those nurses on cardiac surgery are awfully competent,” said Cassi. “If they said the patient was dark blue, he was dark blue.”

“Then I give up,” said Jerry, taking out a ten-dollar bill and slipping it into the pocket of Robert’s white jacket.

“You don’t have to pay me,” said Robert. “I was just kidding.”

“Bullshit,” said Jerry. “If it had been a pulmonary embolism I’d have taken your money.” Jerry walked over to where he’d hung his white jacket.

“Congratulations, Robert,” said Cassi. “Looks like you got case number eighteen. Compared to the number of open-heart surgery cases they’ve done over the last ten years, that’s getting close to being statistically significant. You’ll get a paper out of this yet.”

“What do you mean ‘me’?” asked Robert. “You mean ‘us,’ don’t you?”

Cassi shook her head. “No, Robert. This whole thing has been your idea from the start. Besides, now that I’ve switched to psychiatry, I can’t hold up my end of the work.”

Robert looked glum.

“Cheer up,” said Cassi. “When the paper comes out, you’ll be glad you didn’t have to share authorship with a psychiatrist.”

“I was hoping this study would get you to come up here frequently.”

“Don’t be silly,” said Cassi. “I’ll still come up, especially when you find new SSD cases.”

“Cassi, let’s go,” called Jerry impatiently. He had the door held open with his foot.

Cassi gave Robert a peck on the cheek and ran out. Jerry took a playful swipe at her as she passed through the door. Not only did she evade the blow, but she managed to give Jerry’s necktie a sharp tug as she passed.

“Where’s your woman friend?” asked Jerry as they reached the main part of the pathology department. He was still struggling to straighten his tie.

“Probably in Robert’s office,” said Cassi. “She said she needed to sit down. I think the autopsy was a little much for her.”

Joan had been resting with her eyes closed. When she heard Cassi she got unsteadily to her feet. “Well, what did you learn?” She tried to sound casual.

“Not much,” said Cassi. “Joan, are you all right?”

“Just a mortal wound to my pride,” said Joan. “I should have known better than watch an autopsy.”

“I’m terribly sorry . . .” began Cassi.

“Don’t be silly,” said Joan. “I came voluntarily. But I’d just as soon leave if you’re ready.”

They walked down to the elevators where Jerry decided to use the stairs since it was only four flights to the medical floor. He waved before disappearing into the stairwell.

“Joan,” said Cassi, turning back to her. “I really am sorry I forced you up here. I’d gotten so accustomed to autopsies as a path resident that I’d forgotten how awful they can be. I hope it didn’t upset you too much.”

“You didn’t force me up here,” said Joan. “Besides, my squeamishness is my problem, not yours. It’s just plain embarrassing. You’d think after four years of medical school I’d have gotten over it. Anyway, I should have admitted it and waited for you in Robert’s office. Instead I acted like a fool. I don’t know what I was trying to prove.”

“Autopsies were hard for me at first,” said Cassi, “but gradually it became easier. It is astounding what you can get used to if you do it enough, especially when you can intellectualize it.”

“For sure,” said Joan, eager to change the subject. “By the way, your men friends do run the gamut. What’s the story with Jerry Donovan? Is he available?”

“I think so,” said Cassi, punching the elevator button again. “He was married back in med school but then divorced.”

“I know the story,” said Joan.

“I’m not sure if he’s dating anyone in particular,” said Cassi. “But I could find out. Are you interested?”

“I wouldn’t mind asking him to dinner,” said Joan pensively. “But only if I could be sure he’d put out on the first date.”

It took a moment for Joan’s comment to penetrate before Cassi burst out laughing. “I think you sized him up pretty well,” she said.

“The macho medicine man,” said Joan. “What about Robert?” Joan lowered her voice as they got on the elevator. “Is he gay?”

“I suppose so,” said Cassi. “But we’ve never discussed it. He’s been such a good friend, it has never mattered. He used to rate my boyfriends back in medical school, and I used to listen until I met my husband because Robert was always right. But he must have been jealous of Thomas because he never liked him.”

“Does he still feel that way?” asked Joan.

“I can’t say,” said Cassi. “That’s the only other subject that we never talk about.”