A Brain

by Robin Cook

  “Good. Don’t leave without me,” said Martin.

  Within minutes Kristin was called. Almost simultaneously another door opened and Dr. Harper emerged.

  Philips recognized Harper as one of the residents he’d seen on occasion in and around the hospital. He’d never met the man but his polished head was hard to forget. Philips got up and introduced himself. There was an awkward pause. As a resident, Harper did not have an office and since both examining rooms were occupied, there was no place to talk. They ended up in the narrow corridor.

  “What can I do for you?” asked Harper, somewhat suspiciously. It was bizarre for the Assistant Director of Neuroradiology to be visiting Gynecology, since their interests and expertise lay at opposite ends of the medical spectrum.

  Philips began his questioning in rather vague terms, expressing an interest in the way the clinic was manned, how long Harper had been there, and whether he enjoyed it. Harper’s responses were abrupt and his small eyes darted over Philips’ face as he explained that the university’s clinic was a two-month elective rotation for a senior resident, adding that it had become a symbolic stepping-stone for being asked to join the staff following completion of the residency.

  “Look,” Harper said after a pause, “I’ve got a lot of patients to see.” Martin realized that instead of making the man relax, his questions were making him more ill-at-ease.

  “Just one more thing,” said Philips. “When a Pap smear is reported as atypical, what’s usually done?”

  “That depends,” said Harper warily. “There’re two categories of atypical cells. One is atypical but not suggestive of tumor, whereas the other is atypical and suggestive of tumor.”

  “Whether it’s in either class, shouldn’t something be done? I mean, if it’s not normal, it should be followed up. Isn’t that right?”

  “Yeah,” said Harper evasively. “Why are you asking me these questions?” He had the distinct feeling he was being backed into a corner.

  “Just out of interest,” said Martin. He held up Collins’ chart. “I’ve come across several patients who’d had atypical Pap smears in this clinic. But reading the GYN notes, I can’t find any reference to Schiller’s test, thoughts about a biopsy, or colposcopy . . . just repeat smears. Isn’t that . . . irregular?” Philips eyed Harper, sensing his discomfort. “Look, I’m not here casting any blame. I’m just interested.”

  “I couldn’t say anything unless I saw the chart,” said Harper. He’d intended the comment to end the conversation.

  Philips handed Collins’ chart to Harper and watched as the resident opened it. When Harper read the name, “Katherine Collins,” his face became tense. Martin watched curiously as the man rapidly flipped through the chart, too quickly to read anything adequately. When he got to the end, he looked up and handed it back.

  “I don’t know what to say.”

  “It is irregular, isn’t it?” asked Martin.

  “Put it this way: It’s not the way I’d handle it. But I’ve got to get back to work now. Excuse me.” He pushed past Philips, who had to press up against the wall to give him room to go by.

  Surprised at the precipitous end to the conversation, Martin watched the resident hurry into one of the examining rooms. Philips had not intended his questions to be taken personally and he wondered if he had sounded more accusatory than he realized. Still the resident’s response when he had opened Katherine Collins’ chart had been strange. Philips had no doubt about that.

  Believing there was no point in trying to talk further with Harper, Martin went back out to the receptionist and inquired after Kristin Lindquist. Ellen Cohen at first acted as if she hadn’t heard the question. When Philips repeated it, she snapped that Miss Lindquist was with the nurse and would be out shortly. Having not liked Kristin initially, the receptionist hated her even more now that Philips seemed interested in her. Unaware of Ellen Cohen’s jealousies, Martin just felt incredibly confused about the university’s GYN clinic.

  A few minutes later, Kristin came out of the examining room, aided by a nurse. Martin had seen the nurse before, probably in the cafeteria, remembering her thick black hair, which she wore piled on her head in a tight bun.

  He stood up as the woman approached the desk and heard the nurse instruct the receptionist to give Kristin an appointment in four days. Kristin looked very pale.

  “Miss Lindquist,” Martin called. “Are you finished?”

  “I think so,” said Kristin.

  “How about that X ray?” asked Philips. “Do you feel up to it?”

  “I think so,” managed Kristin, again.

  Suddenly the black-haired nurse strode back to the desk. “If you don’t mind my asking, what kind of X ray are you talking about?”

  “A lateral skull film,” said Martin.

  “I see,” said the nurse. “The reason I ask is that Kristin has had an abnormal Pap test and we’d prefer she avoid abdominal or pelvic films until her Pap smear status is normal.”

  “No problem,” said Philips. “In my department we’re only interested in the head.” He’d never heard of such an association between Pap smears and diagnostic X rays, but it sounded reasonable.

  The nurse nodded, then left. Ellen Cohen slapped an appointment card in Kristin’s waiting hand before turning and pretending to busy herself with her typewriter. “California slut,” she muttered under her breath.

  Martin guided Kristin away from the bustle of the clinic and led her through a connecting door into the hospital proper. Once the fire door had been passed, the scene looked very pleasant in contrast to the clinic. Kristin was surprised.

  “These are private offices for some of the surgeons,” explained Philips as they walked down a long carpeted hall. There were even oil paintings on the freshly painted walls.

  “I thought the whole hospital was old and decayed,” said Kristin.

  “Hardly.” An image of the subterranean morgue flashed through Philips’ mind, immediately merging with his recent vision of the GYN clinic. “Tell me, Kristin, as a patient, how do you find the university’s clinic?”

  “That’s a difficult question,” said Kristin. “I hate gynecology appointments so much that I don’t think I can give a fair answer.”

  “How does it compare with your past experience?”

  “Well, it is terribly impersonal, at least it was yesterday when I saw the doctor. But today I only saw the nurse and it was better. But then again I didn’t have to wait today like I did yesterday, and all they did was draw more blood and recheck my vision. I didn’t have another exam. Thank God.”

  They reached the elevator area and Philips pressed the button.

  “Ms. Blackman also had the time to explain my Pap smear. Apparently it wasn’t bad. She said it was only Type II, which is common and almost reverts to normal spontaneously. She told me it was probably caused by cervical erosion and that I should use a weak douche and avoid sex.”

  Martin was momentarily nonplussed at Kristin’s forthrightness. Like most physicians, he was surprisingly unaware that his being a doctor encouraged people to make their secrets accessible.

  Arriving in X-ray, Philips sought out Kenneth Robbins and put Kristin in his hands for the single lateral skull film he wanted. Since it was after four, the department was relatively quiet and one of the main X-ray rooms was empty. Robbins took the X ray and disappeared into the darkroom to load the film into the automatic developer. While Kristin waited, Martin stationed himself at the slot in the main hall where the film would emerge.

  “You look like a cat watching a mouse hole,” said Denise. She’d come up behind Philips and surprised him.

  “I feel like one. Down in GYN I found a patient with similar symptoms to Marino and the others and I’m holding my breath to see if there’s the same radiological picture. How did your angiograms go this afternoon?”

  “Very well, thank you. I appreciate your letting me work on my own.”

  “Don’t thank me. You earned it.”


  At that moment the tip of Kristin’s X ray appeared, then oozed out of the roller, dropping into the holding bin. Martin snatched it up and put it on the viewer. His finger scanned back and forth in an area approximately over Kristin’s ear.

  “Damn,” said Philips. “It’s clear.”

  “Oh come on!” protested Denise. “Don’t tell me you actually want the patient to have the pathology.”

  “You’re right,” said Martin. “I don’t mean to wish it on anyone. I just want a case that I can X-ray properly.”

  Robbins stepped out of the darkroom. “You want any more films, Dr. Philips?”

  Martin shook his head, took the X ray and walked into the room where Kristin was waiting. Denise followed.

  “Good news,” said Philips, waving the film. “Your X ray is normal.” Then he told Kristin that perhaps they should repeat it in a week if her symptoms persisted. He asked her for her phone number and gave her his direct-dial number in case she had any questions.

  Kristin thanked him and tried to stand. Immediately she had to support herself by grabbing the X ray table as a wave of dizziness hit her. The room seemed to spin in a clockwise direction.

  “Are you all right?” Martin asked, holding her arm.

  “I think so,” said Kristin, blinking. “It was that same dizziness. But it’s already gone.” What she didn’t say was that she again smelled the familiar obnoxious odor. It was too bizarre a symptom for her to share. “I’ll be all right. I think I’d better get home.”

  Philips offered to get her a taxi but she insisted she was all right. As the elevator door closed she waved and even managed a smile.

  “That was a very clever way to get an attractive young woman’s phone number,” said Denise, as she walked back to Philips’ office. Rounding the corner, Martin was relieved when he saw that Helen had left. Denise took one look in his room and gasped in disbelief. “What the hell?”

  “Don’t say anything,” said Philips, making his way through the debris to his desk. “My life is disintegrating and smart comments are not going to help.” He picked up the messages Helen had left. As he had expected, there were calls marked important from Goldblatt and Drake. After staring at them for a minute, he allowed the two pieces of paper to waft in a gentle spiral into his large institutional wastebasket.

  Then he turned on the computer and fed in Kristin’s skull film.

  “Well! How’s it going?” said Michaels, appearing at the doorway. He could tell from the litter that little had changed since the morning visit.

  “Depends on what you’re referring to,” said Philips. “If you mean the program, the answer is fine. I’ve only run a few films, but so far it is performing with an accuracy of about a hundred-ten percent.”

  “Wonderful,” said Michaels, clapping his hands.

  “It’s more than wonderful,” said Philips. “It’s fantastic! It’s the only thing around here that has been going right. I’m just sorry I haven’t had more time to work on it. Unfortunately, I’m behind on my regular work. But I’m going to stay here for a while tonight and run as many films as I can.” Philips saw Denise turn and look at him. He tried to read her expression but the noisy clatter of the typewriter rapidly spewing out the report captured his attention. Michaels saw what was happening and he came up behind Philips to look over his shoulder. From Denise’s perspective, the two of them looked like proud parents.

  “It’s reading a skull film I just took on a young woman,” Martin said. “Her name is Kristin Lindquist. I thought maybe she’d have the same abnormality as those other patients I described to you. But she doesn’t.”

  “Why are you so committed to this one abnormality?” asked Michaels. “Personally, I’d rather see you spending your time on the program itself. There will be time for this kind of investigative fun later.”

  “You don’t know doctors,” said Martin. “When we release this little computer on the unsuspecting medical community it’s going to be like confronting the Medieval Catholic Church with Copernican astronomy. If we could present a new radiological sign that the program had discovered, it would make acceptance much easier.”

  When the print-out typewriter paused, Philips tore off the report. His eyes scanned the sheet rapidly, then riveted on one central paragraph. “I don’t believe it.” Martin grabbed the film and put it back up on his viewer.

  With his hands blocking out most of the X ray, Philips isolated a small area at the back of the skull. “There it is! My God! I knew the patient had the same symptoms. The program remembered the other cases and was able to find this very small example of the same abnormality.”

  “And we thought it was subtle on the other films,” said Denise looking over Philips’ shoulder. “This just involves the tip of the occipital pole, not the parietal or temporal region.”

  “Maybe it’s just earlier in the progress of the disease,” suggested Philips.

  “What disease?” asked Michaels.

  “We don’t know for certain,” said Martin, “but several of the patients who showed this same density abnormality were suspected of multiple sclerosis. It’s a shot in the dark.”

  “I don’t see a thing,” admitted Michaels. He put his face very close to the X ray, but it was no use.

  “It’s a textural quality,” said Martin. “You have to be aware of what the normal texture is before you can appreciate the difference. Believe me, it’s there. The program is not making it up. Tomorrow I’ll get the patient back and cone down right over the area. Maybe with some better films you’ll be able to see it.”

  Michaels admitted that his appreciation of the abnormality was not critical. After turning down an offer of dinner in the hospital cafeteria, Michaels excused himself. At the door he again begged Martin to spend more time running old films through the computer, saying there was a good chance the program would pick up all sorts of new radiologic signs, and if Philips took time to follow up each one, the program would never get debugged. With a final wave, Michaels departed.

  “He’s eager, isn’t he,” said Denise.

  “With good reason,” said Martin. “He told me today that to handle the program they have designed a newer processor that has a more efficient memory. Apparently it’s going to be ready shortly. When it is, I’ll be the only one holding them up.”

  “So you’re planning to work tonight?” asked Denise.

  “Of course.” Martin looked at her and for the first time noticed how tired she was. She’d gotten almost no sleep the night before and had worked all day.

  “I was hoping you’d be interested in coming over to my apartment for a little dinner and perhaps finish what we had started last night.”

  She was being deliberately erotic and Martin was an easy target. Sexual expression would be a wonderful way to deal with the frustrations and exasperations of the day. But he knew he had to do some work and Denise was too important to just be used as he had the nurses when he was an intern needing to diffuse his tension.

  “I’ve got to catch up a little,” he said at last. “Why don’t you go home early. I’ll call and perhaps come over later.”

  But Denise insisted on waiting while he went over all the angiograms and the day’s CAT scans, which had been dictated by the neuroradiology fellows. Even if his name did not appear on the reports, Philips checked everything done in the department.

  It was a quarter to seven when they scraped back their chairs and stood up to stretch. Martin turned to look at Denise, but she hid her face.

  “What’s the matter?”

  “I just don’t like you to see me when I look so awful.”

  Shaking his head in disbelief, he reached out and tried to lift her chin, but she shook off his hand. It was amazing how within seconds of switching off the viewer she had changed from an engrossed academician to a sensitive woman. As far as Martin was concerned she appeared tired but as appealing as ever. He tried to tell her, but she wouldn’t believe it. She kissed him quickly, then said she was going home fo
r a long bath, and that she hoped to see him later. Like a bird in flight, she left.

  It took Martin a few moments to collect himself. Denise had the power to short-circuit his brain. He was in love and he knew it. Getting out Kristin’s telephone number he dialed, but there was no answer. He decided to take a file of correspondence to proofread while he ate dinner in the cafeteria.

  It was nine-fifteen when Martin cleared up the last of the dictation and correspondence. During the same time he had been able to run twenty-five more old films through the flawlessly functioning computer. Meanwhile Randy Jacobs was making frequent trips back and forth from the file room. He’d been returning the completed envelopes, but since he’d pulled several hundred additional ones, Philips’ office was even more jumbled and disorganized than before.

  Using the phone at his desk, Philips again tried Kristin’s number. She answered on the second ring.

  “I’m a little embarrassed,” he said, “but looking at your X ray more closely, I think there is a very small area that needs closer examination. I was hoping you’d be willing to come back, like tomorrow morning?”

  “Not in the morning,” said Kristin. “I’ve missed classes two days in a row. I’d rather not miss more.”

  They agreed on three-thirty. Martin assured her that she would not have to wait. When she arrived she was supposed to come directly to Philips’ office.

  Hanging up, Martin leaned back in his chair and let the day’s problems wash over him. The conversations with Mannerheim and Drake were exasperating, but at least they were consistent with the personalities of the two men. The conversation with Goldblatt was different. Philips had not expected such an attack from someone who had been his mentor. Martin was quite sure that Goldblatt had been responsible for his being named Assistant Chief of Neuroradiology four years ago. So it didn’t make sense. If hostility to the computer work was behind Goldblatt’s conduct, they were in for more trouble than either Philips or Michaels had anticipated. The thought made Martin sit up and search for the list he’d made of the patients with the potentially new radiologic sign. Corroboration of the new diagnostic technique had assumed greater importance. He found the list and added Kristin Lindquist’s name.