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 consulti
ng 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.
“ ‘Overinvolved’ was the expression my informant used, and we both nodded wisely. Getting emotional about a patient was one thing. Making a public show of it was something else. But he was a foreigner, and his specialty was inevitably a chamber of horrors, so we were inclined to give him more latitude than we might have otherwise. Better him than me, we were thinking.
“The next time I ran into him was late one night, here in the hospital. I was admitting a twelve-year-old girl in DKA, and was just finishing writing up the orders when I felt something looming over my shoulder. It was Schott, standing there visibly impatient, with the hand-wringing and the sweaty face, beside himself over something.
“ ‘I’m so glad you’re here,’ he started off. He looked over his shoulder. ‘There is a patient,’ he explained, and gestured at one of the rooms in the corner of the PICU. His expression had a guilty quality about it, as though he expected the pursuit to start up at any moment.
“The patient was another one of his treatment failures. This one was in cardiogenic shock, whether from the stress of circulating a volume that was more crystalloid than blood, or some direct toxicity of the treatment, it wasn’t clear. There were some nuances to the treatment of shock in pediatric patients, he said. He would like to call a consult. But we had no pediatric cardiologist in town. Would I mind?
“Of course I didn’t mind, not even when the child continued so unstable I was there in the PICU until dawn, at which point the patient went into arrest and that was it. A mercy, really, considering how things were going.
“To his credit, Schott stayed as well, even though his contributions consisted of little more than hand-wringing, and muttering in German that I assumed was prayer. And he had the goodness to call the child’s parents (something I had forgotten, but then I didn’t know anyone involved in this case besides Schott) and tell them to come in. They arrived in time to witness their child’s last moments. Almost the last. Once the final attempt at resuscitation got under way, the nurses had to pull them out of the room.
“We left the PICU together, Schott and I. I had stayed while he broke the news to the parents, and kept him company as we both went out to the parking lot. It was early June, not yet five in the morning; the air was cool and still and dawn was just breaking. The light was crepuscular, but even so I could see Schott’s features clearly when I turned to him and said, ‘How many does that make?’
“You see, I had realized, as we made our way down the stairs, all this time Schott snuffling and muttering at my elbow, that I was angry. I suppose part of it was at being kept up all night on a consult I didn’t think I was going to find the heart to bill anyone for. And part of it was Schott’s pathetic performance. But most of it was the righteous anger anyone would feel at finding a colleague with such a trail of destruction at his heels.
“Schott stared at me for a moment, those watery eyes very wide. His expression wasn’t surprise, or incomprehension. Where someone truly surprised might stiffen, he just sagged. It was clear he had been expecting something like this.
“You knew this was so because he had an answer ready to hand. ‘How many?’ he whispered. And those eyes of his went far away again. ‘The number is seven here. With this one, eight.’
“ ‘Eight?’ I had been thinking it was three, at most. But while I was choking down that number, I found myself contemplating that little detail he had almost slipped by.
“ ‘And elsewhere?’ I demanded. ‘How many before you came here?’
“Schott stood facing me in the silent parking lot, the first light of dawn at his back. Somewhere in the trees birds were beginning to stir.
“ ‘Before?’ he said softly. ‘Before, there was one.’
“ ‘Only one?’ I was sarcastic.
“ ‘No,’ he said, so quietly I could barely hear him over the rising clatter of the birds. ‘There was one. Who lived.’
“ ‘One?’ I fairly roared it.
“ ‘One,’ he said again, and as he said this pathetic little word the sadness in his face silenced me momentarily—long enough for him to turn and quickly walk away.
“I took all this home with me, but in the few hours I had to get myself ready for a day in the clinic, there was no time to think. Somewhere in the back of my mind I had a vague notion about ‘doing something.’ But whenever I tried to bring that notion out into the light of day it refused to take on any solid form.
“What was there to do? He was an oncologist, after all: oncology patients die. I supposed I could do some reading, see if the regimens he’d been prescribing were at least on the level. For all I knew he was some kind of laetrile-peddling quack, despite the German credentials. I left for the clinic that morning with the intention of spending lunch in the hospital’s tiny library, but of course there was no time for lunch, and when my last patient had finally left and my last note was on the chart, it was past seven. I shelved the notion for tomorrow.
“Tomorrow followed tomorrow, and I confess my intention to ‘do something’ languished there for months. Then a call from the father of one of my patients, a healthy if slightly accident-pro
ne ten-year-old boy I hadn’t seen since his previous birthday, dragged the whole mess back into view.
“The father’s tale began in the emergency room, where Robert had been brought several months earlier with a fracture of the proximal humerus acquired while falling from a tree. In the course of the initial assessment, the admitting orthopod had ordered a routine set of films, which had revealed that Robert’s fracture was only a symptom of a more serious problem. He had a Ewing’s sarcoma, an extremely rare bone cancer of children.
“At that time, the treatment of choice was amputation, and the orthopod fully expected to be performing one before nightfall, until events supervened in the form of Dr. Schott.
“What he had been doing in the emergency room I do not know, and the record does not cast any light on the question either. I think Schott simply volunteered himself to Robert’s parents.
“According to the father, Schott offered an alternative to amputation. As part of an investigational trial, he said, he had a drug that could be effective in Ewing’s. He had been persuasive. The orthopod had been uncooperative. The parents went with Schott and his more enthusiastic view of the situation, and Robert had been scheduled for induction therapy the following day.
“And it had worked. We had no scintigraphy back then, but X-rays obtained six weeks after induction showed no tumor where the tumor had been, and once Robert had recovered from the anemia, the mucositis, and the hundred other horrors Schott’s cocktail had afflicted him with, he had been up and toddling about. He had no eyebrows, and the hair that grew back in on his scalp was a ‘weird, fuzzy stuff,’ his father said, but they didn’t care: their boy was alive, and whole.
“Two months later, Robert had begun complaining of pain in his left thigh. X-rays showed a large mass erupting out of the femur.
“At this point, the father’s account grew a little sketchy. Someone had wanted to call in the orthopod, someone else had argued against it. Schott’s was the only unambiguous response. He had offered another round of chemotherapy. Another experimental regimen. At which point sanity (which had been one conspicuously missing feature of the case) returned long enough for the boy’s mother to suggest a call to me.
Internal Medicine: A Doctor's Stories Page 19