Internal Medicine: A Doctor's Stories (27 page)

In the lounge chair next to the lamp sat Hawley, a pediatrician, and by far the oldest in the room. He had been long established in his practice when the rest of us began. Two of us had been his patients. A solo practitioner, he shared call with the two larger pediatric practices in town, which explained his presence that night, although some of us harbored a suspicion that he would have been here anyway: he was that kind of doctor, one of the old school that took its obligations more seriously than we do now, to the point of abandoning any life of his own. We were all a little in awe of him, a feeling tempered by the contempt younger doctors feel for the antiquated notions of the old.

We kept our distance from him, however, for another reason entirely. He was different. There was a tendency to produce outlandish statements bordering on a kind of clinical mysticism which made everyone uncomfortable, partly because he seemed oblivious to their effect on the rest of us. Or perhaps he was aware, and simply didn’t give a damn. In any case, he gave every indication of thinking differently from the rest of us, and, given his seniority, and the primitive reverence his patients held him in, this difference made the rest of us nervous. No one had ever caught him in a mistake, or reading a journal.

He was also fond of telling us long, apparently pointless case histories, involving patients or practitioners who had departed this scene before most of us had been born. He offered these tales (for that was what they were, and whether based on actual cases or entirely fabricated was an open question) whether we wanted to hear them or not, and with a disregard for our obvious impatience that made the entire performance intolerable: maddening because so impervious, and so benign. It seemed mean to resent this in him, and yet we all did. Not that he noticed. In telling these stories he seemed to retreat into himself, so that his involuntary audience came to feel they had been ensnared in a novel kind of meditative practice, through which the old man sought some inner meaning that had not yet revealed itself—and clearly, as far as the exasperated auditor could tell, never would.

But what was perhaps most exasperating was that bland indifference: listening to old Hawley droning on and on, whether in the hospital coffee shop or at some random nursing station, one never got the feeling that the telling was motivated by some inner doubt or turmoil. There are cases that bother you, we all knew that, the ones that leave behind names and faces that pop out at you in the night. There’s always some residue of doubt. Not with Hawley. The cases he dredged up were gruesome enough, but in telling them he seemed the embodiment of clinical equanimity. He seemed to be rehearsing the case, not in search of absolution as the rest of us would, but for some other reason entirely. It seemed—and I think this was, ultimately, why none of us could stand him—that he was telling them for our benefit.

As the night settled in more heavily around us—with the familiar call-night sensation of ill impending—you could almost hear the silent plea directed at Hawley’s impassive figure. For a time, it seemed our prayers were heard. The muffled chirping of pagers became sporadic and then fell quiet, and he might have been asleep. He sat motionless in the glow of the lamp, eyes closed, facial features arrested by the light, waxen in their various droops and sags.

We had seen this before: he had an uncanny knack for sitting still like this, only to break out without warning in some interminable yarn that would not stop until it had reached its farcically implausible conclusion. He was not above claiming personal experience with spontaneous combustion. But on this unusual night as the stillness deepened it seemed possible to hope that, this once, we might be spared. We knew better, of course.

So when the old man straightened in his chair we felt both doomed and affirmed in our pessimism. He resettled his flabby white hands in his lap (hands faultlessly clean, the nails as well tended as a funeral-parlor cadaver’s), and cleared his throat. Benson, the sleeping anesthetist, rolled over and moaned in a dream two words that might have been “not again.”

“I knew a man,” Hawley began, the formula with which most of his stories began, as immediately recognizable as “once upon a time” (and, some said, with as much relation to reality). Then, equally part of the ritual, a long pause ensued, during which Hawley could be seen to settle into himself, into whatever trance these stories of his put him into, which enabled him to go on talking in the face of any amount of indifference or contempt.

When he found his voice again, it had taken on a low, almost monotone quality. People claimed that he could speak, when he had started going at this pitch, without moving his lips, and this was what allowed him to go on at such length. Indeed on this night I had the opportunity of watching him closely, and it did seem as if the voice emerged without any movement of his face, his features lying as impassive in the lamplight as shadows on the face of the moon.

“I knew a man,” he said again, seeming to have rediscovered the sentence’s original direction, “who had a most unhealthy relationship with hope.”

A groan made its way around the room, followed by Hawley’s bland gaze. He might have been a blind man, for all the expression it held. It came to rest, blindly, benignly, on Benson. “Do you think he’s sleeping?” he asked, then turned away, the question clearly of no interest, one of those mysterious flourishes that clogged up all his tales, seeming to insinuate something but in reality only inane.

“His name was—let’s call him Schott. If anybody ever needed to be Schott, it would have been him. You wouldn’t remember him: this all happened a long time ago. I wasn’t more than a year or two out of residency. I had come back from Cambridge an apostle of light, ministering in this forsaken wilderness.”

He gurgled briefly in what must have been a laugh.

“If there’s anything to be said for practicing in the place where you grew up, it’s that people will hold you to a certain standard of honesty. A part of that standard requires that you stay pretty much the person you’ve always been. In going away and coming back a doctor, I’d pushed that clause to the limit; coming back as an apostle of light just wasn’t on the cards.

“But strangers were another matter, which is how this man Schott came on the scene. He had a German name, which is nothing remarkable in these parts. But he also had a German accent, and a medical degree from the University of Göttingen, where he had also completed a residency in internal medicine, followed by a three-year research fellowship at Hopkins, in oncology.

“Why a man with that background would wind up in a backwater such as this was a question no one worried about: he was a foreigner, and that was reason enough. And besides, having an oncologist in the first place was something of a coup, the field being still in its infancy. The German accent was more of an asset than not, even though this was at a time when German still meant, for most people, Nazi. But the University of Göttingen! And the research. I think the Chamber of Commerce believed he was going to single-handedly start up some kind of institute. You actually heard people talking about the Mayo. People thought that way then.

“Schott arrived the year after I did. I didn’t meet him for two or three months. Hardly anyone did. Too busy with his research was everybody’s understanding, so no one resented it.

“He also had a pretty busy practice. This was back in the day when things like childhood leukemia were nothing but a death sentence. It was hard to believe that people like Schott thought they could treat it. Everyone knew you could induce remission in ALL with amethopterin, but not many people thought it was a good idea: the disease was fatal, the remissions were brief, why not let the kids die in peace? This was before Holland et al. turned the thing around. Our frame of reference had more to do with the early work on nitrogen mustards: back then you knew, if you knew anything, that the initial discoveries came out of autopsies done on victims of gas attacks in the War. So it wasn’t anything you wanted to get close to. It just had a bad aroma about it.

“In retrospect, it’s amazing Schott had the nerve to get anywhere near it, what with his accent and his German degree. I think he was just tone-deaf to the whole issue. So was I, for that matter, once I discovered that I needed Schott and his German science.

“The case that brought us into contact was one of those things that happens only rarely in pediatrics, but they can make you reconsider the whole thing. A five-year-old boy, brought in by his mother for fatigue, listlessness, the whole spectrum of vague complaints that can be anything from maternal anxiety to—something bad. Which this was. The physical exam told me everything I needed to know: tachycardia, pallor, and a spleen I could feel halfway down to the pelvic brim. I patted the little fellow on the head, told his mother we would need to draw some blood, and scheduled them to come back the next day, when I was going to tell her that her child had leukemia and was going to die.

“There was no getting away from it. I was going to have to talk to that woman tomorrow, and then over the next few weeks I was going to watch that child die gasping for breath. Thinking about it, I wandered into the corridor and stood looking out the window at the parking lot.

“I didn’t know for half a minute that anyone was with me until I heard a voice at my ear, soft, the accent giving it an insinuating quality that always grated on me.

“ ‘You must have something on your mind,’ it said.

“I jumped, and turned, and found myself face-to-face with Schott. He had an oddly small face, the features jammed together as though from a lifetime of looking through keyholes. His eyes had a vague, watery quality that made him look as though he ought to be wearing glasses. He nodded at the view through the window and said, ‘I come here, too, myself, when it is time to think.’

“In my surprise at this sudden appearance, even more so at his peculiar insight into my inner turmoil, I leapt perhaps a little too eagerly at the coincidence of this man’s appearance at that particular moment.

“ ‘You’re just the man I need to see,’ I heard myself cry out, and laid before him the outline of the case.

“Schott listened to my story, nodding and pulling at his lower lip, his face mirroring my own concern. When I was done that lip curled up in a smile that made his eyes focus happily off in the distance: it gave his expression a wistfulness I hadn’t expected from a German scientist, and it made me like him suddenly. ‘I can help,’ he said, and that made me like him even more.

“When I explained to the mother the next day just what her child had, I stumbled over my words in my hurry to get on to the good news, that there was a doctor who—And there I hung up for a moment. What was it I imagined Schott could offer her child? A cure? I had been about to say it, even though I knew that no one cured leukemia. I think I stammered up some euphemism like ‘a treatment.’ It was enough that when the woman hoisted up her son by one hand and followed me to Schott’s consulting room, I felt I had an ally—and a ray of hope—in what would otherwise have been a dismal, lonely tragedy.

“I still remember the expression on Schott’s face as I ushered the two of them into his office. We found him seated at his desk, under the impressive, black-letter German diplomas and the shelves heavy with journals and books. He stood stiffly at attention as I made the introductions, but his gaze as he shook hands so formally with the mother was all on the child at her feet, and the expression on his face was a curious thing: avid and tender and something else I couldn’t identify at the moment, but which I understood later was fear.

“I didn’t understand that he intended to start treating the child then and there. I didn’t pick up on that part of it until the end of the day, when I got a call from Schott, letting me know he had admitted my patient for what he expected to be two weeks of chemotherapy.

“It didn’t work. The child died before the two weeks were out: tumor lysis; renal failure. At the time, there were only six dialysis machines in the world, and they were all in Seattle. It’s not a painful way to die. There was that, anyway.

“I was surprised at how badly Schott took it. You wouldn’t have thought all that Germanic formality would have permitted the man to cry, but crying was what I found him doing in the stairwell that afternoon.

“ ‘Ach,’ he said, when I found him sobbing. ‘I’m sorry.’ He was actually wringing his hands. I wasn’t sure who he was apologizing to, but I was afraid it was me.

“You see, I had started to have doubts, once it was clear the treatment was going wrong, about my putting the child in Schott’s hands. I had known better. We all knew better. Leukemia was fatal. All this chemotherapy did was take a dying child and turn its death from something tragic into something squalid.

“But Schott’s unhappiness was affecting, and at the moment none of that crossed my mind. I laid a hand on his shoulder and said something to the effect that he had tried, it could have been worse, there had been some benefit. What that benefit had been I wouldn’t have wanted to say: it was just the kind of empty thing one says to a colleague in distress.

“But the effect those words had on Schott was remarkable. He straightened, squared his shoulders, and for a moment I thought he was going to click his heels. ‘You are right,’ he said.

“ ‘With every failure, we advance our knowledge.’

“And that was all. He turned, and without another word made his way back up the stairs.

“I didn’t think of him for a while after that. But a month or two later I heard a rumor about another one of his ‘treatments.’ This one had ended spectacularly, with the patient exsanguinating on the threshold of the emergency room. Schott had been there, the reports had it, wringing his hands, almost as frantic as the child’s parents, almost as much in the way. The emergency room physician had had to physically remove him from the scene.