Michael Crichton - A Case of Need

“Not now,” I said.

“You promised.”

“I know,” I said. “But not now.”

“I knew you’d do this to me,” Murph said. “Sarah will hate me.” Sarah was his wife. She thrived on gossip.

“Sorry, but I just can’t.”

“Hell of a thing to do to an old friend.”

“Sorry.”

“If she divorces me,” Murph said, “I’m naming you as co-defendant.”

I ARRIVED AT THE MALLORY PATH LABS AT THREE. The first man I ran into was Weston, who was looking tired. He gave me a lopsided smile of greeting.

“What did you find out?” I said.

“The findings are negative,” he said, “for pregnancy.”

“Oh?”

“Yes.” He picked up the folder containing the path protocol and thumbed through it. “No question.”

“I called here earlier and was told the report was three months’ pregnancy.”

Weston said carefully, “Whom did you talk with?”

“A secretary.”

“There must have been some kind of mistake.”

“I guess,” I said.

He handed me the folder. “Want to see the slides, too?”

“Yes. I’d like to.”

We walked to the pathologists’ reading room, a long room divided into individual cubicles, where the pathologists kept their microscopes and slides, and wrote up their autopsies.

We stopped at one booth.

“There it is,” Weston said, pointing to a box of slides. “I’ll be curious to have your opinion on them when you’re through.”

He left me, and I sat down in front of the scope, switched on the light, and began work. There were thirty slides in the box, made from all the major organs. Six had been made from different parts of the uterus: I began with them.

It was immediately clear that the girl was not pregnant. The endometrium was not hyperplastic. If anything, it appeared dormant and atrophic, with a thin proliferative layer, few glands, and decreased vascularity. I checked several other slides to be sure. They were all the same. Some contained thromboses from the scraping, but that was the only difference.

As I looked at the slides I considered their meaning. The girl had not been pregnant, yet she had been convinced she was. Therefore her periods must have stopped. That could account for the dormant appearance of the endometrium. But what had caused the periods to stop? I ran through the differential in my mind.

In a girl of this age, neurogenic factors came immediately to mind. The pressures and excitement of beginning school and moving to a new environment might have temporarily suppressed menstruation—but not for three months, and not with the associated signs: obesity, change in hair distribution, and so on.

Then there were hormonal disorders. Adrenal virilizing syndromes, Stein-Leventhal, irradiation. All of them seemed unlikely for one reason or another, but there was one quick way to find out.

I put the adrenal slide under the stage. There was good evidence of cortical atrophy, particularly in the cells of the zona fascicularis. The zona glomerulosa appeared normal.

Rule out virilizing syndromes and adrenal tumor.

Next I looked at the ovaries. Here the changes were striking. The follicles were small, immature, withered-looking. The whole organ, like the uterine endometrium, had a dormant appearance.

Rule out Stein-Levanthal and ovarian tumor.

Finally, I put the thyroid slide under the stage. Even under the lowest power, the atrophy of the gland was apparent. The follicles were shrunken and the lining cells were low. Clear hypothyroidism.

That meant that the thyroid, adrenals, and ovaries were all atrophic. The diagnosis was clear, though the etiology was not. I opened the folder and read through the official report. Weston had done it; the style was brisk and direct. I came to the micro write-ups. He had noted the endometrium was low and aberrant-looking, but he had considered the other glands to be “of normal appearance, question mark early atrophic changes.”

I shut the folder and went to see him.

HIS OFFICE WAS LARGE, lined with books, and very neat. He sat behind an old, heavy desk smoking a briar pipe, looking scholarly and venerable.

“Something wrong?” he asked.

I hesitated. I had been wondering whether he had covered up, whether he had joined the others who were out to frame Art. But that was ridiculous; Weston couldn’t be bought, not at his age, not with his reputation. Nor was he particularly close to the Randall family. He would have no reason to falsify the report.

“Yes,” I said. “I wondered about your micro diagnosis.”

He puffed the pipe calmly. “Oh?”

“Yes. I’ve just reviewed the slides, and they seem pretty atrophic to me. I thought perhaps—”

“Well, John,” Weston said, chuckling, “I know what you’re going to say. You thought perhaps I’d want to review them.” He smiled at me. “I have reviewed them. Twice. This is an important postmortem and I did it as carefully as I know how. The first time I examined the slides, I felt as you did, that they seemed to show pan hypopituitarism affecting all three target organs—thyroid, adrenals, gonads. I felt that very strongly, so I went back to the gross organs. As you yourself say, the gross organs were not strikingly abnormal.”

“It might have been recently acquired,” I said.

“Yes,” he said, “it might. That’s what makes it so difficult. Then, too, we’d like a look at the brain, to check for evidence of neoplasm or infarction. But that’s not possible; the body was cremated this morning.”

“I see.”

He smiled up at me. “Sit down, John. It makes me nervous to have you standing like that.” When I was sitting, he said, “Anyway I looked at the gross, and then went back to the slides. This time I was less certain. I wasn’t fully convinced. So I checked some old cases of pan hypopit, reviewed the old slides, and finally looked at the Randall slides a third time. By then I felt I could not be certain of a diagnosis of pituitary dysfunction. The more I looked, the less certain I felt. I wanted some kind of corroboratory evidence—brain pathology, or X rays, or blood hormones. That was why I called Jim Murphy.”

“Oh?”

“Yes.” His pipe went out; he relit it again. “I suspected you’d taken the blood sample to do estradiol tests, and that you’d get Murphy to do it. I wanted to know if you’d also decided to have other hormone levels checked—TSH, ACTH, T 4, anything that might help.”

“Why didn’t you just call me?”

“I did, but your lab didn’t know where you were.”

I nodded. Everything he had said made perfect sense. I felt my body slowly relaxing.

“By the way,” Weston said, “I understand some skull films of Karen Randall were taken a while back. Any idea what they showed?”

“Nothing,” I said. “They were negative.”

Weston sighed. “Pity.”

“I’ll tell you something interesting though,” I said.

“What’s that?”

“They were ordered because she complained of blurring vision.”

Weston sighed. “John, do you know the most common cause of blurring vision?”

“No.”

“Lack of sleep,” Weston said. He pushed the pipe to the side of his mouth and held it in his teeth. “What would you do if you were in my position? Make a diagnosis on the basis of a complaint which led to negative X rays?”

“The slides are suggestive,” I reminded him.

“But only suggestive.” He shook his head slowly. “This is already a confused case, John. I’m not going to make it more confused by throwing in a diagnosis I’m not sure about. After all, I may be called into court to defend it. I’d rather not stick my neck out. If the prosecution or the defense wants to find a pathologist to review the material and stick his neck out, that’s fine. The material is here for anyone to see. But I’m not going to do it. My years in the courtroom have taught me one thing, at least.”