Thomas still did not say anything, although he nodded at the truth of the comment. As he pulled on his own shirt, he thought of Norman Ballantine, that white-haired, friendly old doc whom everyone loved and applauded. The fact of the matter was that Ballantine probably shouldn’t still be operating, although no one had the nerve to tell him. It was common knowledge in the department that one of the chief thoracic resident’s jobs was to assign himself to all of Ballantine’s cases so that he could help the chief when he blundered. So much for academic medicine, thought Thomas. Ballantine, thanks to the residents, got reasonable results, and his patients and their families worshipped him despite what went on when the patient was anesthetized.
   Thomas had to agree with Larry’s comment. He also thought that it would be infinitely more appropriate if he, Dr. Thomas Kingsley, was chief. After all, he did most of the surgery, for God’s sake. It was he, more than any other single person, who had made Boston Memorial the place to have any cardiac surgery. Even Time magazine had said as much.
   Yet Thomas did not know if he wanted to be chief any longer. At one time it was all he could think about. It had been one of his driving forces, pushing him on to greater efforts and more personal sacrifice. It had seemed part of a natural progression, and colleagues had started talking about it while he was still a fellow. But that was quite a few years ago, before all the administrative bullshit had reared its ugly head and showed just how much it could interfere in his practice.
   Thomas stopped dressing and stared ahead into the distance. He felt an emptiness inside of him. Comprehending that one of his long sought-after goals was potentially no longer attractive was depressing, especially when the goal was finally within his grasp. Maybe there was no place to go… maybe he’d reached his apogee. God, what an awful thought!
   “I’m awfully sorry to hear about your wife,” said Larry as he sat down to put on his shoes. “It really is a shame.”
   “What do you mean?” asked Thomas, pronouncing each word with deliberate precision. He took immediate offense that a subordinate like Larry would presume to be so familiar.
   Larry, oblivious to Thomas’s response, bent to tie his shoes. “I mean about her diabetes and her eye problem. I heard she’s got to have a vitrectomy. That’s terrible.”
   “The surgery is not definite,” snapped Thomas.
   Hearing the anger in Thomas’s voice, Larry looked up. “I didn’t mean it was necessarily definite,” he managed. “I’m sorry I brought it up. It must be difficult for you. I just hoped that she was okay.”
   “My wife is perfectly fine,” said Thomas angrily. “Furthermore, I don’t think that her health is any of your business.”
   “I’m sorry.”
   There was an uncomfortable silence as Larry quickly finished with his shoes. Thomas tied his tie and splashed on Yves St. Laurent cologne with rapid, irritated motions.
   “Where did you hear this rumor?” asked Thomas.
   “From a pathology resident,” said Larry. “Robert Seibert.”
   Larry closed his locker and told Thomas he’d be in the recovery room if he was needed.
   Thomas ran a comb through his hair, trying to calm down. It just wasn’t his day. Everyone seemed intent on upsetting him. The idea that his wife’s ill health was a topic of idle conversation among the resident staff seemed inexplicably galling. It was also humiliating.
   Placing the comb back in his locker, Thomas noticed a small plastic container. Feeling a rising inner tension and the stirrings of a headache, he flipped open the lid of the bottle. Snapping one of the scored yellow tablets in two, he popped the half into his mouth. Hesitant, he then popped in the other half as well. After all, he deserved it.
   The tablets tasted bitter, and he needed a drink from the fountain to wash them down. But almost immediately he felt relief from his growing anxiety.

   The Friday afternoon cardiac surgery conference was held in the Turner surgical teaching room diagonally across the hall from the surgical intensive care unit. It had been donated by the wife of a Mr. J. P. Turner, who’d died in the late nineteen-thirties, and the decor had an Art Deco flavor. The room provided seating for sixty, half the medical school class size in 1939. In the front there was a raised podium, a dusty blackboard, an overhead rack of ancient anatomy charts, and a standing skeleton.
   It had been at Dr. Norman Ballantine’s insistence that the Friday meeting be held in the Turner teaching room because it was close to the ward, and, as Dr. Ballantine put it, “It is the patients that it’s all about.” But the small group of a dozen or so looked lost among the sea of empty seats and distinctly uncomfortable behind the spartanly designed desks.
   “I think we should get the meeting under way,” called Dr. Ballantine over the hum of conversation. The people took their seats. Present at the meeting were six of the eight cardiac surgeons on staff, including Ballantine, Sherman, and Kingsley, as well as various other doctors and administrators, and a relatively new addition, Rodney Stoddard, philosopher.
   Thomas watched Rodney Stoddard sit down. He looked like he was in his late twenties despite the fact that he was mostly bald and his remaining hair was such a light color that it was difficult to see it. He wore thin wire-rimmed glasses and an expression of constant self-satisfaction. To Thomas it seemed as if the man were saying, “Ask me about your problem because I know the answer.”
   Stoddard had been hired at the university’s insistence. Until recently doctors were committed to trying to save all their patients. But now, with the advent of such expensive and complicated procedures as open-heart surgery, transplants, and artificial organs, hospitals had to pick and choose to whom to give these life-saving operations. For the time being, these techniques were limited by extraordinary costs and by the space available in the sophisticated units needed for aftercare. In general the teaching staff tended to favor patients with multisystemic disease, who did not always do well, while private physicians such as Thomas leaned toward otherwise healthy, productive members of society.
   Looking at Rodney, Thomas allowed an ironic smile to steal across his face. He wondered just how self-confident Rodney would feel if he held a man’s heart in his hand. That was a time for decision, not discussion. As far as Thomas was concerned, Rodney’s presence at the meeting was one more indication of the bureaucratic soup in which medicine was drowning.
   “Before we start,” said Dr. Ballantine, extending his arms with hands spread out as if to quiet a crowd, “I want to be sure that everyone has seen the article in this week’s Time magazine rating the Boston Memorial as the center for cardiac bypass surgery. I think we deserve it, and I want to thank each and every one of you for helping us reach this position.” Ballantine clapped, followed by George and a smattering of others.
   Thomas, who’d sat near the door in case he was called to the recovery room, glowered. Ballantine and the other doctors were taking credit for something that was due largely to Thomas and to a lesser extent to two other private surgeons who happened to be absent. When he had gone into surgery, Thomas thought he would avoid the bullshit that surrounded most other professions. It was going to be him and the patient against disease! But as Thomas looked around the room, he realized that almost everyone at the meeting could interfere with his work because of one aggravating problem—the limited number of cardiac surgical beds and associated OR time. The Memorial had become so famous that it seemed as if everyone wanted to have their bypass there. People literally had to wait in line. Especially in Thomas’s practice. He had been limited to nineteen OR slots a week and he had a backlog of more than a month.
   “While George passes out the schedule for next week,” said Dr. Ballantine, extending a stack of stapled papers to George, “I’d like to recap this week.”
   He droned on as Thomas turned his attention to the schedule. His own patients were scheduled by his nurse, who collated the necessary information and got it over to Ballantine’s secretary, who typed it up. It contained a capsule medical history of each patient, a listing of significant diagnostic data, and an explanation of the need for surgery. The idea was that everyone at the conference would go over each patient and make sure that the operation was needed or advisable. But in reality it rarely happened, except if you missed the meeting. Once when Thomas had been absent, the anesthesiology department had canceled several of his cases, resulting in a row no one was likely to forget. Thomas continued reviewing the sheets until Ballantine mentioned something about deaths. Thomas looked up.
   “Unfortunately there were two surgical deaths this week,” said Dr. Ballantine. “The first was a case on the teaching service, Albert Bigelow, an eighty-two-year-old gentleman who could not be weaned from the pump after a double-valve replacement. He’d been scheduled as an emergency. Is there word on the autopsy yet, George?”
   “Not yet,” said George. “I must point out that Mr. Bigelow was a very sick cookie. His alcoholism had seriously affected his liver. We knew we were taking a risk going to surgery. You win some and you lose some.”
   There was a silence. Thomas commented sarcastically to himself that Mr. Bigelow’s untimely demise had prompted a stimulating discussion. The galling part was that it was this kind of patient that was keeping Thomas’s patients waiting.
   Ballantine glanced around, and when no one spoke he continued: “The second death was a patient of mine, Mr. Wilkinson. He died last night. He was autopsied this morning.”
   Thomas saw Ballantine look over at George, who shook his head almost imperceptibly.
   Ballantine cleared his throat and said that both cases would be discussed at the next death conference.
   Thomas wondered at the silent communication. It brought to mind the weird comment George had made up in the lounge. Thomas shook his head.
   Something was going on between Ballantine and George, and Thomas felt a twinge of uneasiness. Ballantine had a unique position in the medical center. As chief of cardiac surgery, he held an endowed chair with the university and was paid a salary. But Ballantine also had a private practice. Ballantine was a holdover from the past, bridging as he did the full-time salaried men like George and the private staff, like Thomas. Of late Thomas had begun to think that Ballantine, whose skills were obviously on the decline, was beginning to favor the prestige of being a professor over the rewards of private practice. If that were true, it could cause trouble by upsetting the balance between the full-time staff and the private physicians, which in the past had always tilted toward the latter.
   “Now, if everyone will turn to the last page of the handout,” said Dr. Ballantine, “I’d like to point out that there has been a major scheduling change.”
   There was a simultaneous rustle as everyone flipped the pages. Thomas did the same, placing the papers on the arm of his chair. He did not like the sound of a major scheduling change.
   The last page was divided vertically into four columns, representing the four rooms used for open-heart surgery. Horizontally the page was divided into the five days of the work week. Within each box were the names of the surgeons scheduled for that day. OR No. 18 was Thomas’s room. As the fastest and busiest surgeon, he was assigned four cases on each day except Friday when he had three because of the conference. The first thing Thomas checked when he looked at the page was OR No. 18. His eyes widened in disbelief. The schedule suggested that he’d been cut to three cases a day, Monday through Thursday. He’d lost four slots!
   “The university has authorized us to hire another full-time attending for the teaching service,” Dr. Ballantine was saying proudly, “and we have started a search for a pediatric cardiac surgeon. This, of course, is a major advance for the department. In preparation for this new situation, we are expanding the teaching service by an additional four cases per week.”
   “Dr. Ballantine,” began Thomas, carefully controlling himself. “It appears from the schedule that all four additional teaching slots are being taken from my allotted time. Am I to assume that is just for next week?”
   “No,” said Dr. Ballantine. “The schedule you see will hold until further notice.”
   Thomas breathed out slowly before speaking. “I must object. I hardly think it’s fair that I should be the sole person to give up OR time.”
   “The fact of the matter is that you have been controlling about forty percent of the OR time,” said George. “And this is a teaching hospital.”
   “I participate in teaching,” snapped Thomas.
   “We understand that,” said Ballantine. “You’re not to take this personally. It is plainly a matter of more equitable distribution of OR time.”
   “I’m already over a month behind on my patient schedule,” said Thomas. “There isn’t that kind of demand for teaching cases. There aren’t enough patients to fill the current teaching slots.”
   “Don’t worry,” said George. “We’ll find the cases.”
   Thomas knew what the real issue was. George, and most of the others, were jealous of the number of cases Thomas did and how much money Thomas earned. He felt like getting up and punching George right in the face. Glancing around the room, Thomas noticed that the rest of the doctors were suddenly busy with their notes, papers, or other belongings. He could not count on any of the people present to back him up.
   “What we all have to understand,” said Dr. Ballantine, “is that we are all part of the university system. And teaching is a major goal. If you feel pressure from some of your private patients, you could take them to other institutions.”
   Thomas’s anger and frustration made it hard for him to think clearly. He knew, in fact everybody knew, that he could not just pick up and go to another hospital. Cardiac surgery required a trained and experienced team. Thomas had helped build the system at the Memorial, and he depended on the structure.
   Priscilla Grenier spoke up, saying they might be able to add an additional OR room if they got an appropriation for another heart-lung machine and perfusionist to run it.
   “That’s a thought,” responded Dr. Ballantine. “Thomas, perhaps you’d be willing to chair an ad hoc committee to look into the advisability of such expansion.”
   Thomas thanked Dr. Ballantine, struggling to keep his sarcasm to a minimum. He said that with his current workload it was not possible to accept Ballantine’s offer immediately, but that he’d think about it. At the moment he had to worry about putting off patients who might die before they had OR time. Patients with a ninety-nine-percent chance of living long, productive lives if they did not find their OR time sacrificed to some sclerotic wino whom the teaching service wished to experiment on!
   On that note the meeting was adjourned.
   Struggling to keep his temper under control, Thomas went up to Ballantine. George had, of course, beat Thomas to the podium, but Thomas interrupted.
   “Could I speak to you for a moment?” asked Thomas.
   “Of course,” said Dr. Ballantine.
   “Alone,” said Thomas succinctly.
   “I was heading over to the ICU anyway,” said George amiably. “I’ll be in my office if you need me.” George gave Thomas a pat on the shoulder before leaving.
   To Thomas, Ballantine was the Hollywood image of the physician, with his soft white hair combed back from a deeply lined but tanned and handsome face. The only feature that somewhat marred the overall effect were the ears. By anyone’s standards they were large. Right now Thomas felt like grabbing and shaking them.
   “Now, Thomas,” said Dr. Ballantine quickly. “I don’t want you getting paranoid about all this. You have to understand that the university has been putting pressure on me to delegate more OR time to teaching, especially with the Time article. That kind of publicity is doing wonders for the endowment program. And as George pointed out, you have been controlling a disproportionate amount of hours. I’m sorry you had to learn about it like this, but…”
   “But what?” asked Thomas.
   “You are in private practice,” said Dr. Ballantine. “Now if you’d agree to come full-time, I can guarantee a full professorship and…”
   “My title as Assistant Clinical Professor is fine with me,” said Thomas. Suddenly he understood. The new schedule was another attempt at pressuring him into giving up his private practice.
   “Thomas, you do know that the chief of cardiac surgery who follows me will have to be full-time.”
   “So I’m to look at this cut in my OR time as a fait accompli,” said Thomas, ignoring Ballantine’s implications.
   “I’m afraid so, Thomas. Unless we get another OR, but, as you know, that takes time.”
   Abruptly Thomas turned to go.
   “You’ll think about coming aboard full-time, won’t you?” called Dr. Ballantine.
   “I’ll consider it,” said Thomas, knowing he was lying.
   Thomas left the teaching room and started down the stairs. At the first landing he stopped. Gripping the handrail and closing his eyes as tightly as possible, he let his body shake with sheer anger. It was only for a moment. Then he straightened up. He was back in control. After all, he was a rational individual, and he’d been up against bureaucratic nonsense long enough to deal with it. He’d suspected that Ballantine and George were up to something. Now he knew. But Thomas wondered if that were all. Maybe it was something more than the OR schedule change because he still had the anxious feeling something else was going on that he should know about.

Three

   Cassi always experienced a degree of apprehension when she dipped the test tape into her urine. There was always the chance that the color of the tape would change and indicate she was losing sugar. Not that a little sugar in her urine was all that big a deal, especially if it occurred only once in a while. It was more an emotional thing; if she was spilling sugar, then she was not in control. It was the psychological aspect that was disturbing.
   The light in the toilet was poor, forcing Cassi to unlatch the stall door in order to get a good look at the tape. It had not changed its color. Having gotten so little sleep the night before and having cheated that afternoon with a fruit yogurt snack, she wouldn’t have been too surprised to see a little sugar. Cassi was pleased that the amount of insulin she was giving herself and her diet were in balance. Her internist, Dr. Malcolm McInery, talked occasionally of switching her to a constant insulin-infusion device, but Cassi had demurred. She was reluctant to alter a system that seemed to be working. She did not mind giving herself two injections a day, one before breakfast and one before dinner. It had become so routine as to be effortless.
   Closing her right eye, Cassi looked at the test tape. There was just a vague sensation of light as if she were looking through a wall of ground glass. She wished that she didn’t have the problem with her eye because the idea of blindness terrified her more, in some ways, than the idea of death. The possibility of death she could deny, just like everyone else. But denying the possibility of blindness was difficult with the condition of her left eye there to remind her each and every day. The problem had happened suddenly. She’d been told that a blood vessel had broken, causing blood to enter into the vitreous cavity.
   As she washed her hands, Cassi examined herself in the mirror. The single overhead light was kind, she decided, giving her skin more color than she knew it possessed. She looked at her nose. It was too small for her face. And her eyes: they curved unnaturally upwards at the outer corners as if she had her hair pulled back too tightly. Cassi tried to look at herself without concentrating on any single feature. Was she really as attractive as people said? She’d never felt pretty. She had always thought that diabetes was indelibly stamped in bold letters across her forehead. She was convinced that her disease was a major flaw that everyone could see.
   It hadn’t always been that way. In high school Cassi had tried to reduce it to a small aspect of her life. Something she could compartmentalize. And although she was conscientious about her medicine and diet, she did not want to dwell on it.
   Yet this approach made her parents, mostly her mother, understandably concerned. They felt that the only way she would be able to maintain the discipline the disease required was to make it her major focus. At least that was the way Mrs. Cassidy had dealt with the problem.
   The conflict came to a head at the time of the senior prom.
   Cassi came home from school beside herself with excitement and anticipation. The prom was to be held in a fashionable local country club, followed by a breakfast back at the school. Then the entire class was to head down to the New Jersey shore for the rest of the weekend.
   Unexpectedly Cassi had been asked to the prom by Tim Bartholomew, one of the more popular boys in the school. He’d talked with Cassi on a number of occasions following a physics class they shared. But he’d never asked Cassi out, so the invitation came as a total surprise. The thrill of going out with a desirable boy to the biggest social event of the year was almost too much for Cassi to bear.
   Cassi’s father was the first to hear the good news. As a rather dry professor of geology at Columbia University, he didn’t share the same enthusiasm as Cassi but was pleased she was happy.
   Cassi’s mother was less enthusiastic. Coming in from the kitchen, she told Cassi that she could go to the prom but had to come home instead of going to the breakfast.
   “They don’t cook for diabetics at such affairs,” said Mrs. Cassidy, “and as far as going to the shore for the weekend, that is completely out of the question.”
   Not expecting this negative response, Cassi was ill-prepared to deal with it. She protested through tears that she’d demonstrated adequate responsibility toward her medicine and diet and that she should be allowed to go.
   Mrs. Cassidy was adamant, telling Cassi that she was only thinking of her welfare. Then she said that Cassi had to accept the fact that she was not normal.
   Cassi screamed that she was normal, having emotionally struggled with that very issue for her entire adolescence.
   Mrs. Cassidy grasped Cassi’s shoulders and told her daughter that she had a chronic, life-long disease and that the sooner she accepted the fact the better off she’d be.
   Cassandra flew to her room, locking her door. She refused to talk with anyone until the next day. When she did, she informed her mother that she’d called Tim and told him that she couldn’t go to the prom because she was ill. She told her mother that Tim had been surprised because he’d not known she had diabetes.
   Staring at her reflection in the hospital mirror, Cassi brought herself back to the present. She wondered to what degree she had overcome her disease intellectually. Oh, she knew a lot about it now and could quote all sorts of facts and figures. But had that knowledge been worth the sacrifices? She didn’t know the answer to that question and probably never would. Her eyes strayed up to her hair, which was a mess.
   After taking out her combs and hairpins, Cassi gave her head a shake. Her fine hair tumbled down around her face in a disorganized mop. With practiced hands she carefully put it back up, and when she emerged from the bathroom she felt refreshed.
   The few things she’d brought with her for the overnight in the hospital fitted easily into her canvas shoulder bag despite the fact that it already contained a large folder of reprinted medical articles. She’d had the bag since college, and although it was soiled and threadbare in places, it was an old friend. It had a large red heart on one side. Cassi had been given a briefcase on graduation from medical school, but she preferred the canvas bag. The briefcase seemed too pretentious. Besides, she could get more into the bag.
   Cassi checked her watch. It was five-thirty, which was just about perfect timing. She knew that Thomas would be heading down the stretch, seeing his last office patients. As Cassi hefted her things, she remarked to herself that the regular schedule was another benefit of psychiatry. As a medical intern or pathology resident, she was never finished much before six-thirty or seven, and at times worked to eight or eight-thirty. On psychiatry she could count on being free after the four to five afternoon team meeting, provided she wasn’t on call.
   Stepping into the corridor, Cassi was initially surprised to find it empty. Then she remembered that it was dinner-time for the patients, and as she passed the common room, she could see most of the patients eating from their trays in front of their TV sets. Cassi ducked into her cubbyhole office and collected the charts she’d been extracting. She only had four patients, including Colonel Bentworth, and she’d spent a portion of the afternoon carefully going over their charts and making three-by-five index cards on each case.
   With the canvas bag over her shoulder and the charts in her arms, Cassi went down to the nurses’ station. Joel Hartman, who was on call that night, was sitting in the station, talking to the two nurses. Cassi deposited the charts in their respective slots and said good night. Joel told her to have a good weekend and to relax because he’d have her patients cured by Monday. He said he knew just how to handle Bentworth because he had been in ROTC in college.
   As she walked down to the first floor, Cassi could feel herself beginning to relax. Her first week on psychiatry had been a trying and difficult period, one that she would not like to relive.
   Cassi took the interior pedestrian crosswalk to the Professional Building. Thomas’s office was on the third floor. She paused outside the polished oak door, gazing at the shining brass letters: THOMAS KINGSLEY, M.D., CARDIAC AND THORACIC SURGERY, and felt a thrill of pride.
   The waiting room was tastefully decorated with Chippendale reproductions and a large Tabriz rug. The walls were powder blue and hung with original art. The door leading to the inner office was guarded by a mahogany desk occupied by Doris Stratford, Thomas’s nurse-receptionist. As Cassi entered, Doris looked up briefly, then went back to her typing when she recognized who it was.
   Cassi approached the desk.
   “How’s Thomas doing?”
   “Just fine,” said Doris, her eyes on her paper.
   Doris never looked Cassandra in the eye. But over the years Cassi had become accustomed to the fact that her illness made some people uncomfortable. Doris was obviously one of them.
   “Would you let him know I’m here?” said Cassi.
   Cassi got a fleeting glimpse of Doris’s brown eyes. There was an aura of petulance about her expression. Not enough for Cassi to complain about but enough to let her know that Doris did not appreciate the interruption. She didn’t answer Cassi but rather depressed the button on an intercom unit and announced that Dr. Cassidy had arrived. She went directly back to her typing.
   Refusing to allow Doris to irritate her, Cassi settled herself on the rose-colored couch and pulled out the articles she wanted on borderline personality. She started to read but found herself looking over the top of the paper at Doris.
   Cassi wondered why Thomas kept Doris. Granted she was efficient, but she seemed moody and irritable, hardly the qualities one would like in a physician’s office. She was presentable although not overly attractive. She had a broad face with large features and mousy brown hair pulled back in a bun. She did have a good figure; Cassi had to admit that.
   Letting her eyes drop back to her paper, Cassi forced herself to concentrate.

   Thomas looked across the polished surface of his desk at his last patient of the day, a fifty-two-year-old lawyer named Herbert Lowell. Thomas’s office was decorated like his waiting room, except the walls were a forest green. The other difference was that the furniture was authentic Chippendale. The desk alone was worth a small fortune.
   Thomas had examined Mr. Lowell on several occasions and had reviewed the coronary arteriograms done by Mr. Lowell’s cardiologist, Dr. Whiting. To Thomas the situation was clear. Mr. Lowell had anginal chest pain, a history of a mild heart attack, and radiographic evidence of compromised arterial circulation. The man needed an operation, and Thomas had told Mr. Lowell as much. Now Thomas wanted to terminate the visit.
   “It’s such an irreversible decision,” Mr. Lowell was saying nervously.
   “But still a decision that must be made,” said Thomas, standing up and closing Mr. Lowell’s folder. “Unfortunately I’m on a tight schedule. If you have any further questions you can call.” Thomas started for the door like a clever salesman indicating the issue was beyond further negotiation.
   “What about the advisability of a second opinion?” asked Mr. Lowell hesitantly.
   “Mr. Lowell,” said Thomas, “you can get as many opinions as you’d like. I will be sending a full consult letter back to Dr. Whiting, and you can discuss the case with him.” Thomas opened the door leading to the waiting room. “In fact, Mr. Lowell, I would encourage you to see another surgeon because, frankly, I do not feel good about working with people with negative attitudes. Now if you’ll excuse me.”
   Thomas closed the door behind Mr. Lowell, confident the man would schedule the required operation. Sitting down, he gathered the material he needed for his Grand Rounds presentation the following morning, and then started signing the consultation letters Doris had left for him.
   When Thomas emerged with the signed correspondence, he was not surprised to find Mr. Lowell in the waiting room. Thomas glanced at Cassi, acknowledging her with a brief nod, then turned to his patient.
   “Dr. Kingsley, I’ve decided to go ahead with the operation.”
   “Very well,” said Thomas. “Give Miss Stratford a call next week, and she’ll set it up.”
   Mr. Lowell thanked Thomas and left, closing the door quietly behind him.
   Holding her reports in front of her as if she were reading, Cassi watched her husband going over some notes with Doris. She’d noticed how well he’d handled Mr. Lowell. He never seemed to hesitate. He knew what should be done and he did it. She’d always admired his composure, a quality she felt she lacked. Cassi smiled as her eyes traced the sharp lines of his profile, his sandy hair, and his athletic body. She found him extraordinarily attractive.
   After the insecurities of the day, in fact the entire week, Cassi wanted to rush up and throw her arms around him. But she knew instinctively that he would not care for that kind of show of emotion, especially with Doris there. And Cassi knew he was right. The office was not the place for such behavior. Instead, she put the reprint back into the folder and the folder back into the canvas bag.
   Thomas finished with Doris, but it wasn’t until the office door closed behind them that he spoke to Cassi.
   “I’ve got to go to the ICU,” he said, his voice flat. “You can come or wait in the lobby. Your choice. I won’t be long.”
   “I’ll come,” said Cassi, already guessing that Thomas’s day had not been smooth. She had to quicken her step to keep up with him.
   “Was there trouble with your surgery today?” she asked tentatively.
   “Surgery went fine.”
   Cassi decided against further questioning. It was difficult to talk as they threaded their way back into the Scherington Building. Besides, she’d learned from experience that it was usually better to let Thomas volunteer information when he was upset.
   In the elevator she watched while he kept his eyes glued to the floor indicator. He seemed tense and preoccupied.
   “I’ll be glad to get home tonight,” said Cassi. “I need a good night’s sleep.”
   “The weirdos keep you busy last night?”
   “Let’s not have any of your surgeon’s opinions about psychiatry,” said Cassi.
   Thomas didn’t respond, but an ironic smile appeared on his face, and he seemed to relax a little.
   The elevator doors opened on seventeen, and they got out. Thomas walked swiftly ahead. No matter how many years Cassi had spent in hospitals, she always had the same reaction when she found herself on the surgical floor. If it wasn’t fear, it was close to it. The crisis aspect undermined the elaborate denial she used about the implications of her own illness. What mystified Cassi about the response was that she didn’t feel the same way on the medical floor where there invariably were patients with diabetically induced complications.
   As Cassi and Thomas neared the ICU, several waiting relatives recognized Thomas. Like a movie or rock star, he was instantly surrounded. One old woman was intent on touching him as if he were some kind of god. Thomas remained composed, assuring everyone that all the surgery had gone routinely and that they would have to wait for further updates by the nursing personnel. With some difficulty he finally detached himself and entered the ICU where no one dared follow him except Cassi.
   With its enormous number of machines, oscilloscope screens, and bandages, it intensified all of Cassi’s unspoken fears. And in fact, the patients themselves seemed all but forgotten, lost as they were in the tangle of equipment. The nurses and doctors seemed to tend the machines first.
   Thomas went from bed to bed. Each patient in the ICU had his own specially trained nurse to whom Thomas spoke, hardly looking at the patient unless the nurse called his attention to some abnormality. He visually checked all the vital signs which could be seen on the read-out equipment. He glanced at the fluid balance logs, held portable chest X rays up to the overhead light, and looked at electrolyte and blood gas values. Cassi knew enough to know how much she didn’t know.
   As Thomas had promised, he didn’t take long. His patients were all doing well. With Larry Owen in command, the resident staff would deal with all the minor problems that arose during the night. When Thomas and Cassi reemerged, the patients’ families again set upon him. Thomas said that he regretted he didn’t have more time to talk but that everyone was doing well.
   “It must be extraordinarily rewarding to get that kind of feedback from families,” said Cassi as they were walking toward the elevator.
   Thomas didn’t respond immediately. Cassi’s statement reminded him of the pleasure he had felt years earlier when the Nazzaros had greeted him. Their gratitude had meant something. Then he thought about Mr. Campbell’s daughter. He glanced back down the corridor, realizing that he hadn’t seen her.
   “Oh, it’s nice that the relatives are appreciative,” said Thomas without much feeling. “But it’s not that important. It’s certainly not why I do surgery.”
   “Of course not,” said Cassi. “I didn’t mean to imply that.”
   “For me recognition by my teachers and superiors was always more important,” said Thomas.
   The elevator arrived and they got on.
   “The trouble is,” continued Thomas, “now I’m the teacher.”
   Cassi glanced up. To her surprise his voice had an unexpected and uncharacteristic wistfulness. As she watched him, she could see that he was staring ahead, daydreaming.
   Thomas’s mind flashed back to his thoracic residency, a time of unbelievable excitement and adventure. He remembered that he all but lived in the hospital for three years, going home to his drab two-room apartment only to recharge by sleeping for a few hours. In order to excel he had worked harder than he’d ever thought possible. And in the end he was appointed chief resident. In many respects Thomas felt that event had been the crowning achievement of his life. He’d come out on top of a group of gifted people as committed and competitive as himself. Thomas would never forget the moment that each of his attendings congratulated him. There was no doubt, he thought, that surgery and life in general were more rewarding and more fun then. Thankful relatives were nice, but they were no substitute.

  When Cassi and Thomas emerged from the hospital, they were rudely slapped by a wet Boston evening. Gusts of wind lashed the rain in chaotic circles. At six-fifteen it was already dark. The only illumination came from the city lights reflecting off the low, swirling cloud cover. Cassi grasped Thomas about the waist and together they ran for the nearby parking garage.
   Once under shelter, they stomped the moisture from their feet and walked more slowly up the concrete ramp. The wet cement had a surprisingly acrid smell. Thomas still wasn’t acting normally, and Cassi tried to guess what was bothering him. She had the uncomfortable feeling that it was something she’d done. But she couldn’t imagine what. They hadn’t seen each other since the ride in to the hospital Thursday morning, and everything had seemed fine at that time.
   “Are you tired from working last night?” asked Cassi.
   “Yes, I probably am. I haven’t thought too much about it, though.”
   “And your cases? They went okay?”
   “I told you, they went fine,” said Thomas. “In fact I could have done another bypass if they had allowed me to schedule it. I did three cases in the time it took George Sherman to do two and Ballantine, our fearless chief, to do one.”
   “Sounds like you should be pleased,” said Cassi.
   They stopped in front of an anthracite metallic 928 Porsche. Thomas hesitated, looking at Cassi over the top of the car. “But I’m not pleased. As usual there was a host of little things to annoy me, making my work more difficult. It seems to be getting worse, not better, around the Memorial. I’m really fed up. Then to top it all off, at the cardiac surgery meeting, I was informed that four of my weekly OR slots were being expropriated so George Sherman could schedule more of his goddamn teaching cases. They don’t even have enough teaching patients to fill the slots they already have without dredging up patients who have no right to precious space in the hospital.”
   Thomas unlocked his door, climbed in and reached across to open Cassi’s.
   “Besides,” said Thomas, gripping the steering wheel, “I have a feeling something else is going on in the hospital. Something between George Sherman and Norman Ballantine. God! I’ve just had it with all the bullshit!”
   Thomas gunned the engine, then rammed the car back, then forward, the tires screeching in protest. Cassi braced herself against the dashboard to keep herself upright. When he stopped to stick his card into the slot for the automatic gate, she reached over her shoulder for her seat belt. As she locked it in place, she said, “Thomas, I think you should fasten yours, too.”
   “For Chrissake,” yelled Thomas. “Stop nagging me.”
   “I’m sorry,” said Cassi quickly, now certain that she was in some way partially responsible for her husband’s foul mood.
   Thomas weaved in and out of traffic, cutting in front of irate commuters. Cassi was afraid to say anything lest she anger him further. It was like a Grand Prix free-for-all.
   Once they were north of the city, the traffic thinned out. Despite the fact Thomas was going over seventy, Cassi began to relax.
   “I’m sorry I seemed like a pest, especially after an aggravating day,” she said finally.
   Thomas didn’t respond, but his face was less tense and his grip on the steering wheel not as tight. Several times Cassi started to ask if she’d been responsible for upsetting him, but she could not find the right words. For a while she just watched the rain-slicked road rushing toward them. “Have I done something that’s bothered you?” she said at last.
   “You have,” snapped Thomas.
   They rode for a while in silence. Cassi knew it would come sooner or later.
   “It seems Larry Owen knows all about our private medical matters,” said Thomas.
   “It’s no secret that I have diabetes,” said Cassi.
   “It’s no secret because you talk about it so often,” said Thomas. “I think the less said the better. I don’t like us to be the brunt of gossip.”
   Cassi could not remember mentioning anything to Larry about her medical problems, but of course that wasn’t the issue. She was well aware she’d talked to a number of people about her diabetes, including Joan Widiker that very day. Thomas, like her mother, felt Cassi’s disease was not a subject to be shared, even with close friends.
   Cassi looked over at Thomas. The bands of light and shadow from the oncoming cars moved down his face and obscured his expression.
   “I guess I never thought discussing my diabetes affected us,” said Cassi. “I’m sorry. I’ll be more careful.”
   “You know how gossip is in a medical center,” said Thomas. “It’s better not to give them anything to talk about. Larry knew more than just about your diabetes. He knew that you might have to have eye surgery. That’s pretty specific. He said he heard it from your friend Robert Seibert.”
   Now it made sense to Cassi. She knew she hadn’t said anything to Larry Owen. “I did talk to Robert,” she conceded. “It seemed only natural. We’ve known each other so long, and he told me about his surgery. He’s having impacted wisdom teeth out. With his history of severe rheumatic fever he has to be admitted and treated with IV antibiotics.”
   They turned north off Route 128, heading toward the ocean. There were unexpected patches of heavy fog, and Thomas slowed down.
   “I still don’t think talking about such problems is a good idea,” said Thomas, squinting through the windshield. “Especially to someone like Robert Seibert. It’s still beyond me how you can tolerate such an overt homosexual.”
   “We never talk about Robert’s sexual preferences,” said Cassi sharply.
   “I don’t understand how you could avoid the subject,” said Thomas.
   “Robert is a sensitive, intelligent human being and a damn good pathologist.”
   “I’m glad he has some redeeming qualities,” said Thomas, conscious that he was baiting his wife.
   Cassi bit down her reply. She knew that Thomas was angry and was trying to provoke her; she also knew that losing her own temper would accomplish nothing. After a brief silence, she reached across and massaged Thomas’s neck. At first he remained rigid, but after a few minutes she felt him respond.
   “I’m sorry I talked about my diabetes,” she said, “and I’m sorry I talked about my eye condition.”
   Maintaining her massage, Cassi stared out the window with unseeing eyes. A cold fear made her wonder if Thomas was getting tired of her illness. Maybe she’d been complaining too much, especially with all the upset about changing residencies. Thinking about it, Cassi had to admit that Thomas had been distancing himself from her in the last few months, acting more impulsive and with less tolerance. Cassi made a vow to talk less about her illness. She knew, more than anyone, how much pressure Thomas put himself under, and she promised herself not to make it worse.
   Moving her hand up his neck, Cassi thought it would be wise to change the subject.
   “Did anyone say anything about your doing three bypasses while the others did one or two?”
   “No. No one says anything because it’s always the same. There really isn’t anyone for me to compete with.”
   “What about competing with the best: yourself!” said Cassi with a smile.
   “Oh, no!” said Thomas. “Don’t give me any of that pseudopsychology.”
   “Is competition important at this point?” asked Cassi, becoming serious. “Isn’t the satisfaction of helping people return to active lives enough?”
   “It’s a nice feeling,” admitted Thomas. “But it doesn’t help me get beds or OR time even though the patients I propose are the most deserving both from a physical and sociological standpoint. And their gratitude probably won’t make me chief, although I’m not sure I want the position any longer. To tell you the truth, the kick of surgery doesn’t last like it used to. Lately I get this empty feeling.”
   The word “empty” reminded Cassi of something. Had it been a dream? She glanced around the interior of the car, noting the characteristic smell of the leather, listening to the repetitive click of the windshield wipers, letting her mind wander. What was the association? Then she remembered—“empty” was the word Colonel Bentworth used to describe his life in recent years. Angry and empty, that’s what he’d said.
   Emerging from the leafless woods, they sped across the salt marshes. Through the rain-swept window, Cassi caught glimpses of the bleak November landscape. Fall was gone, its last agonal bits of color driven from the naked tree limbs by the rain. Winter was coming, its arrival heralded by the damp chill of the night. They rounded the last bend, thundered over a wooden bridge, and turned into their driveway. Within the bouncing headlights, Cassi could see the outline of their house. It had originally been built around the turn of the century as a rich man’s summer home in the shingle style peculiar to New England. In the nineteen-forties it had been winterized. Its sprawling character and irregular roof line gave it a unique silhouette. Cassi liked the house, perhaps more in summer than in winter. The best part was the location. It was situated directly on a small inlet with a northern view of the sea. Although it was a forty-minute drive north of Boston, Cassi felt the commute was worth it.
   As they pulled up the long driveway, Cassi thought back to when she had first started dating Thomas. They had met when she was sent to the Memorial on her internal medicine rotation her third year of medical school. She’d seen Dr. Thomas Kingsley one day on the ward. He and a group of residents who followed after him like puppies were evaluating a heart attack victim in cardiogenic shock. Cassi had watched Dr. Kingsley with fascination. She’d heard about him and was astonished that he looked so young. She found him extremely attractive, but she never thought someone as dashing as Thomas would ever give her a second glance, except perhaps to ask her an embarrassing medical question. If Thomas had seen her on that first day, he’d given no indication whatsoever.
   Once within the hospital community, Cassi found that it wasn’t as intimidating as she’d feared. She worked very hard and to her amazement suddenly found herself very popular. Previously she had not had time to date, but at the Boston Memorial, work and social life merged. Cassi found herself actively pursued by most of the house staff, who taught her all sorts of things, frivolous and otherwise. Soon even some of the younger attendings began to compete, including a handsome ophthalmologist who could not take no for an answer. Cassi had never met anyone quite so single-minded and persistent, especially in front of his Beacon Hill fireplace. But it had all been fun and not serious until George Sherman asked her out. Without much encouragement from Cassandra, he sent her flowers, small presents, and then, out of the blue, proposed marriage.
   Cassi did not turn George down immediately. She liked him even though she didn’t think she loved him. While she was still thinking over how best to handle things, something even more unexpected occurred. Thomas Kingsley asked her out.
   Cassi remembered the intense excitement she had felt being with Thomas. He had an aura of self-assurance that some people might have labeled arrogance. But not Cassi. She felt he simply knew what he wanted and made decisions with bewildering rapidity. When Cassi tried to talk about her diabetes early in their relationship, Thomas dismissed the subject as a problem of the past. He gave her all the confidence she’d lacked since third grade.
   It had been difficult for Cassi to face George and tell him that not only did she not want to marry him, but she had fallen in love with his colleague. George took the news with seeming composure and said he’d still like to be her friend. When she saw him on occasion in the hospital afterward, he seemed more concerned about her happiness than the fact that she had jilted him.
   Thomas was charming, considerate, and gallant, a far cry from what Cassi expected. She’d heard that he was famous for intense but short relationships. Although he rarely told her that he loved her, he showed it in many ways. He took Cassi on teaching rounds with the fellows and had her come to the OR to see special cases. For their first Christmas together he bought her an antique diamond bracelet. Then on New Year’s Eve he asked Cassandra to marry him.
   Cassi had never intended to get married while in medical school. But Thomas Kingsley was the kind of man that she had not even allowed herself to dream about. She might never meet anyone like him, and since Thomas was in medicine himself, she was confident it would not hinder her work. Cassi said yes and Thomas was ecstatic.
   They were married on the lawn in front of Thomas’s house in view of the sea. Most of the hospital staff had attended and afterward referred to it as the social event of the year. Cassi could remember every moment of that glorious spring day. The sky had been a faraway blue, not unlike Thomas’s eyes. The sea had been relatively calm, with small white caps licked by the westerly breeze.
   The reception was sumptuously catered, the lawn dotted with medieval-looking tents from the top of which heraldic flags snapped in the wind. Cassi had never been so happy, and Thomas appeared proud, ever mindful of the smallest details.
   When everyone had left, Thomas and Cassi walked the beach, mindless of the icy surf grabbing at their ankles.
   Cassi had never felt quite so happy nor quite so secure. They spent the night at the Ritz-Carlton in Boston before leaving for Europe.
   After they had returned from their honeymoon, Cassi went back to her studies but ever mindful of her powerful mentor. In every conceivable way, Thomas helped Cassi. She’d always been a good student, but with Thomas’s help and encouragement, she excelled beyond her wildest expectations. He continued to encourage her to come frequently to the OR to see particularly interesting cases and, while she rotated on surgery, to have her assist, experiences which other medical students could only dream about. Two years later, when it came to graduate study, it was the pathology department that recruited Cassi, not vice versa.
   Perhaps the memory that warmed Cassi’s heart more than any other was the weekend she graduated from medical school. Thomas had acted subdued from the moment they’d awakened that morning, which Cassi had attributed to a complicated surgical case Thomas was expecting. During dinner the night before, he’d told Cassi about a patient who was scheduled to be flown in from out of state. He’d apologized for not being able to take her to the celebration dinner the evening after the commencement, and although she was disappointed, Cassi had assured Thomas that she understood.
   During the ceremony, Thomas had made a fool of himself and embarrassed Cassi by following her to the podium and taking hundreds of flash pictures with his Pentax. Afterward, when Cassi expected him to disappear abruptly to surgery, he led her across the lawn to an awaiting limousine. Confused, Cassi climbed into the long black Cadillac. Inside were two long-stemmed glasses and a chilled bottle of Dom Perignon.
   As if in a fantasy, Cassi was whisked out to Logan Airport and hurried aboard a commuter flight to Nantucket. She tried to protest that she had no clothes and could not possibly go without first returning home, but Thomas had assured her that every detail had been attended to and indeed it had. He showed her a bag, packed with all her makeup and medicine, as well as some new clothes, including the sexiest pink silk Ted Lapidus dress Cassi had ever seen.
   They only stayed for a single night, but what a night. Their room was the master suite of an old sea captain’s mansion that had been converted to a charming country inn. The decor was early Victorian with a huge canopy bed and period wallpaper. There was no television and more importantly, no telephone. Cassi had the delicious sensation of total isolation and privacy.

   Never had she felt so in love nor had Thomas ever been so attentive. They spent the afternoon bicycling along country lanes and running in the icy surf on the beach. Dinner was at a nearby French restaurant. Their candlelit table was set within the shelter of a dormer whose window looked out over Nantucket Harbor. The lights from the anchored sailboats flickered across the water like the sparkle of gemstones. Capping the dinner was Cassi’s graduation present. To her utter astonishment, she gingerly lifted from a small, velvet-lined box the most beautiful three-strand pearl choker she’d ever seen. It was secured in front by a large emerald surrounded by diamonds. As Thomas helped her put the necklace on, he explained that the clasp was a family heirloom, brought from Europe by his great-grandmother.
   Later that night, they discovered that the imposing canopied bed in their room had one unexpected flaw. It squeaked mercilessly whenever they moved. This discovery brought on fits of uncontrolled laughter but did nothing to diminish their enjoyment. If anything, it gave Cassi another wonderful memory of the weekend.
   Cassi’s reverie was broken by the jerk with which Thomas brought his Porsche to a stop in front of their garage. He reached across and pressed the automatic door button inside the glove compartment.
   The garage, also weathered shingle, was completely separate from the house. There was an apartment on the second floor, originally designed for servants, where Thomas’s widowed mother, Patricia Kingsley, resided. She’d moved from the main house when Cassi and Thomas married.
   The Porsche thundered into the garage, then with a final roar, died. Cassi got out, careful that the door did not hit her own Chevy Nova that was parked alongside. Thomas loved his car as much as his own right arm. She also closed the door without too much force. She was accustomed to slamming car doors, something which had been a necessity with the old family Ford sedan. On several occasions Thomas had become livid when she’d reverted back to her old habit despite his lectures on the careful engineering of the Porsche.
   “It’s about time,” said Harriet Summer, their housekeeper, when Thomas and Cassi entered the hall. To emphasize her displeasure, she made sure they saw her check her wristwatch. Harriet Summer had worked for the Kingsleys since before Thomas was born. She was very much the old family retainer and had to be treated as such. Cassi had learned that very quickly.
   “Dinner will be on the table in a half hour. If you’re not there, it will get cold. Tonight’s my favorite TV show, Thomas, so I’m leaving here at eight-thirty come what may.”
   “We’ll be down,” said Thomas, removing his coat.
   “And hang up that coat,” said Harriet. “I’m not going to be picking them up all the time.”
   Thomas did as he was told.
   “What about Mother?” asked Thomas.
   “She’s as she always is,” said Harriet. “She lunched well and she’s expecting a call for dinner, so get cracking.”
   As Thomas and Cassi started upstairs, Cassi marveled at the change in her husband. At the hospital he was so aggressive and commanding, but the minute Harriet or his mother asked him to do something, he obeyed.
   At the top of the stairs, Thomas turned into his second-floor study, saying that he’d see Cassi in a few moments. He didn’t wait for her to reply. Cassi wasn’t surprised, and she continued down the hall toward their bedroom. She knew he liked his study, which was something of a mirror image of his office at the hospital except that it had a wonderful view of the picturesque garage and the salt marshes beyond. The problem was that over the last few months Thomas had begun to spend more and more time there, occasionally even sleeping on the couch. Cassi had not commented, knowing that he was troubled with insomnia, but as the number of nights he spent away from her increased, it had begun to distress her more and more.
   The master bedroom was at the very end of the hall, on the northeast side of the house. It had French doors giving out onto a balcony that had a commanding view of the lawn down to the sea. Next to the bedroom was a morning room facing east. On nice days the sun would stream through the windows. Between the two rooms was the master bath.
   The only part of the house Cassi had redecorated was the bedroom suite. She’d salvaged and repaired the white wicker porch furniture that she had found ignominiously abandoned in the garage. She had chosen bright chintz fabrics for matching comforter, drapes, and seat cushions. The bedroom had been papered with a Victorian-style vertical print; the morning room painted a pale yellow. The combination was bright and cheerful, in sharp contrast with the dark and heavy tones of the rest of the house.
   Cassi had essentially taken over the morning room as her study since Thomas had shown no inclination to share it. She’d found an old country-style desk in the basement, which she’d painted white, and had bought several simple pine bookcases, which she’d painted to match. One of the bookcases had a second role; it served to conceal a small refrigerator that contained Cassi’s medicines.
   After testing her urine again, Cassi went to the refrigerator and removed a package of regular insulin and one of Lente insulin. Using the same syringe, she drew up a half cc of the U100 regular and then one-tenth cc of the U100 Lente. Knowing she had injected herself in her left thigh that morning, she chose a site on her right thigh. The whole procedure took less than five minutes.
   After a quick shower, Cassi knocked on the door to Thomas’s study. When she entered she sensed that Thomas was more relaxed. He’d just finished buttoning a fresh shirt and ended up with more buttons than buttonholes when he got to the top.
   “Some surgeon you must be,” teased Cassi, rapidly fixing the problem. “I met a medical resident whom you impressed last night. I’m glad he didn’t see you buttoning your shirt.” Cassi was eager for light conversation.
   “Who was that?” asked Thomas.
   “You helped him on a resuscitation attempt.”
   “It wasn’t a very impressive effort. The man died.”
   “I know,” said Cassi. “I watched the autopsy this morning.”
   Thomas sat down on the sectional sofa, pulling on his loafers.
   “Why on earth were you watching an autopsy?” he asked.
   “Because it was a post-cardiac-surgical case where the cause of death was unclear.”
   Thomas stood up and began to brush his wet hair. “Did the entire department of psychiatry go up to watch this event?” asked Thomas.
   “Of course not,” said Cassi. “Robert called me and…”
   Cassi paused. It wasn’t until she’d mentioned Robert’s name that she remembered the talk they had had in the car. Fortunately Thomas kept brushing his hair.
   “He said that he thought there was another case for the SSD series. You remember. I’ve spoken to you about that before.”
   “Sudden surgical death,” said Thomas as if he were reciting a lesson in school.
   “And he was right,” said Cassi. “There was no obvious cause of death. The man had had a bypass operation by Dr. Ballantine…”
   “I’d say that was a sufficient cause,” interrupted Thomas. “The old man probably put a suture right through the Bundle of His. It knocks out the heart’s conduction system, and it’s happened before.”
   “Was that your impression when you tried to resuscitate him?” asked Cassi.
   “It occurred to me,” said Thomas. “I assumed it was some sort of acute arrhythmia.”
   “The nurses reported the patient was very cyanotic when they found him,” she said.
   Thomas finished his hair and indicated he was ready for dinner. He gestured toward the hall while he spoke: “That doesn’t surprise me. The patient probably aspirated.”
   Cassi preceded Thomas out into the hall. From the autopsy she already knew the patient’s lungs and bronchial tubes had been clear, meaning he had not aspirated anything. But she didn’t tell that to Thomas. His tone suggested he’d had enough of the subject.
   “I would have thought that beginning a new residency would keep you busy,” said Thomas, starting down the stairs. “Even a residency in psychiatry. Aren’t they giving you enough work to do?”
   “More than enough,” said Cassi. “I’ve never felt quite so incompetent. But Robert and I have been following this SSD series for a year. We were eventually going to publish our findings. Then, of course, I left pathology, but I truly think Robert is onto something. Anyway, when he called me this morning I took the time to go up and watch.”
   “Surgery is serious business,” said Thomas. “Particularly cardiac surgery.”
   “I know,” said Cassi, “but Robert has seventeen of these cases now, maybe eighteen if this new one checks out. Ten years ago SSD only seemed to occur in patients who were in coma. But lately there’s been a change. Patients who have come through surgery with flying colors are seemingly dying postop without cause.”
   “When you consider the number of cardiac cases done at the Memorial,” said Thomas, “you must realize how insignificant a percentage you’re talking about. The Memorial’s death rate is not only well below the average, it’s equal to the best.”
   “I also know that,” said Cassi. “But still it’s fascinating when you consider the trend.”
   Thomas suddenly took Cassi’s arm. “Listen, it’s bad enough that you chose psychiatry as a specialty, but don’t try embarrassing the surgical department about our failures. We are aware of our mistakes. That’s why we have a death conference.”
   “I never intended to cause you embarrassment,” said Cassi. “Besides, the SSD study is Robert’s. I told him today that he was going to have to carry on without me. I just think it’s fascinating.”
   “The competitive climate of medicine always makes other people’s mistakes fascinating,” said Thomas, gently propelling Cassi through the archway into the dining room, “whether they are legitimate mistakes or acts of God.”
   Cassi felt a pang of guilt as she thought about the truth of Thomas’s last statement. She never considered it that way, but it was true.
   As they entered the dining room, Harriet gave them a petulant glance and said that they were late.
   Thomas’s mother was already seated at the table. “It’s about time you two showed up,” she said in her strong, raspy voice. “I’m an old woman. I can’t go this long before dinner.”
   “Why didn’t you eat earlier?” said Thomas, taking his chair.
   “I’ve been by myself for two days,” complained Patricia. “I need some human contact.”
   “So I’m not human, am I?” said Harriet with annoyance. “The truth has finally come out.”
   “You know what I mean, Harriet,” said Patricia with a wave of her hand.
   Harriet rolled her eyes and began serving the casserole.
   “Thomas, when are you going to get that hair of yours cut?” said Patricia.
   “As soon as I have a little extra time,” said Thomas.
   “And how many times do I have to tell you to put your napkin on your lap,” said Patricia.
   Thomas pulled the napkin from the silver holder and threw it onto his lap.
   Mrs. Kingsley placed a minute amount of food in her mouth and began chewing. Her bright blue eyes, similar to Thomas’s, ranged around the table, following Harriet’s progress, waiting for the slightest slip-up. Patricia was a pleasant-looking, white-haired lady with a will of iron. She had smoked Lucky Strikes for years and had deep creases running from her mouth like spokes on a wheel. She was obviously lonely, and Cassi continually wondered why the woman didn’t move to some place where she’d have friends her own age. Cassi knew the thought was motivated by her own interests. After more than three years of eating almost every evening meal with Patricia, Cassi longed for a more romantic end to the day. Despite Cassi’s strong feelings in this regard, she never said anything. The truth of the matter was that Cassi had always been intimidated by this woman, and she’d been reluctant to offend her and thereby incur Thomas’s wrath.
   Still and all, Cassi got along passingly well with Mrs. Kingsley, at least from Cassi’s perspective, and she did feel sorry for the woman, living in the middle of nowhere over her son’s garage.
   After Harriet served, the dinner proceeded in silence, punctuated by silver clanking against china and whispered negatives to Harriet who tried to force seconds on everyone. It wasn’t until they were almost finished that Thomas broke the silence: “My surgeries went well today.”
   “I don’t want to hear about death and disease,” said Mrs. Kingsley. Then she turned to Cassandra and said, “Thomas is just like his father, always wanting to discuss his business. Never could talk about anything important or cultural. Sometimes I think I would have been better off if I’d never married.”
   “You can’t mean that,” said Cassi. “Otherwise you wouldn’t have such an extraordinary son.”
   “Ha!” said Patricia with explosive suddenness. Her laugh echoed in the room, making the Waterford candelabra vibrate. “The only thing truly extraordinary about Thomas is how closely he resembles his father, even to having been born with a clubfoot.”
   Cassi dropped her fork. Thomas had never mentioned this. The image of him as a tiny baby with a twisted foot triggered a wave of sympathy in Cassi, but it was clear from his expression that Thomas was furious with his mother’s revelation.
   “He was a wonderful baby,” continued Patricia, oblivious to her son’s barely suppressed rage. “And a handsome, wonderful child. At least until puberty.”
   “Mother,” said Thomas in a slow, even voice. “I think you’ve said enough.”
   “Fiddlesticks, as they used to say,” returned Patricia. “It’s your turn to be quiet. I’ve been alone here, except for Harriet, for two days, and I should be able to talk.”
   With a final glance of exasperation, Thomas bent over his food.
   “Thomas,” called Patricia after a short silence. “Please remove your elbows from the table.”
   Thomas pushed back his chair and stood up, his face flushed. Without a word, he threw down his napkin and left the room. Cassi heard him stomping upstairs. Then the door to his study slammed. The Waterford candelabra again tinkled gently.
   Caught in the middle, as usual, Cassi hesitated, not knowing what was the best thing for her to do. After a moment of indecision she too stood up, planning on following Thomas.
   “Cassandra,” said Patricia sharply. Then in a more plaintive voice she said, “Please sit down. Let the child be. Eat. I know people with diabetes have to eat.”
   Flustered, Cassi sat down.

  Thomas paced his study, mumbling out loud that it was unfair that he should have to weather such abuse at home after his frustrating day at the hospital. Angrily he wondered why Cassi had stayed with his mother instead of joining him. For a moment he considered returning to the hospital, fantasizing about Mr. Campbell’s daughter and the respect that she would be willing to show him. He remembered her comment about wishing there was something she could do for him.
   But the cold rain beating on the window made the idea of returning to town seem like too much effort. Instead he picked up the journal from the top of his towering pile of reading and sprawled in the burgundy leather armchair next to the fireplace.
   Trying to read, Thomas found his mind wandering. He wondered why his mother could still, after all these years, irritate him so easily. Then Thomas thought about Cassi and the SSD series that she’d been helping Robert Seibert with. There was no doubt in his mind that the kind of publicity that such a study would generate would be extraordinarily detrimental to the hospital. He also knew that Robert just wanted to get his name in print. He didn’t care who he hurt.
   Thomas threw the unread journal to the side and went into the bathroom off the study. Staring into the mirror, he looked at his eyes. He’d always thought he looked young for his age, but now he was not quite so sure. There were dark circles under his eyes, and the lids seemed red and swollen.
   Returning to his study, he sat at his desk and opened the second drawer on the right, removing a plastic bottle. He popped a yellow pill into his mouth and, after a brief hesitation, another. Over at the bar he poured himself a single-malt whiskey and sat down in the leather armchair that had been his father’s. He already felt a lessening of his tension. Reaching over to the side table, he picked up the journal again and tried to read.
   But he couldn’t concentrate. He still felt too much anger. His mind went back to his first week as the chief cardiac surgery resident when he’d been faced with a full intensive care unit and two senior attendings who were demanding space. Without empty available beds, the whole surgical schedule came to a halt.
   Thomas remembered how he had gone into the intensive care unit and carefully checked over each patient to see if any could be moved out. In the end he chose two “gorks,” patients in irreversible coma. It was true they needed round-the-clock special nursing that could only be given in the ICU, but it was also true they were beyond any hope of recovery. Yet when Thomas ordered them moved, their physicians were livid and the nursing staff refused the order. Thomas could still remember the humiliation he experienced when the nursing staff prevailed and the brain-dead patients stayed in the ICU. Not only hadn’t the problem been solved, but Thomas had made additional enemies. It was as if no one understood that surgery, that life-giving process, as well as the costly intensive care unit, were intended for patients who would recover, not the living dead.
   Back at the bar, Thomas refreshed his drink. The ice had diluted the Scotch and blunted its taste. Looking back at the burgundy leather chair, Thomas remembered his father, the businessman, and Thomas wondered what the old man would have thought of him had he lived. Thomas had no idea because, like Patricia, Mr. Kingsley had never been particularly appreciative or supportive of Thomas, always more willing to criticize than commend. Would he have approved of Cassi? Thomas guessed that his father probably would not have thought much of a girl with diabetes.

   Cassi felt anxious after Thomas had left the table. Since he’d already been in a bad mood prior to coming down for dinner, she was afraid he was upstairs seething. Desperately she hunted for conversation but could only elicit “yes” or “no” from Patricia, who acted as if she were pleased she’d driven Thomas away.
   “Did Thomas have a bad clubfoot?” Cassi finally asked, hoping to break the silence.
   “Terrible. Just like his father, who was crippled for life.”
   “I had no idea. I never would have guessed.”
   “Of course not. In contrast to his father, he got treated.”
   “Thank goodness,” said Cassi sincerely. She tried to imagine Thomas with a limp. It was hard for Cassi even to think of Thomas being crippled as a young baby.
   “We had to lock the boy in foot braces at night,” said Patricia, “which was a strain because he screamed and carried on as if I were torturing him.” Patricia dabbed at her lips with her napkin.
   Cassi pictured Thomas as an infant, strapped into his confining foot braces. Undoubtedly it had been a type of torture.
   “Well,” began Patricia, abruptly standing up. “Why don’t you go up to him? Obviously he needs someone. He’s not such a strong boy despite his aggressive manner. I’d go, but he’s obviously chosen you. Men are all the same. You give them everything and they abandon you. Good night, Cassandra.”
   Dumbfounded by Patricia’s rude exit, Cassi sat by herself for a moment. She heard Patricia talking with Harriet, then the front door slammed. The house was quiet except for the squeak of the porch swing as gusts of wind blew it back and forth.
   She got up and began to mount the stairs, smiling suddenly at the thought that she and Thomas had shared a point in common while growing up; they both had had childhood afflictions. Knocking on the study door, Cassi wondered what kind of mood Thomas would be in. After the way he’d behaved in the car, combined with Patricia’s pestering, she expected the worst. But when she entered the room, she was immediately relieved. Thomas was sitting sideways with his legs draped over one arm of his chair, drink in one hand, medical journal in the other. He looked relaxed and handsome. And more important, he was smiling.
   “I trust you and Mother remained cordial,” he said, raising his eyebrows as if there were a chance that the opposite had occurred. “I’m sorry for my abrupt departure, but the old woman was about to drive me mad. I didn’t quite feel up to a scene.” Thomas winked.
   “You’re so predictably unpredictable,” said Cassi, smiling. “Your mother and I had a most interesting conversation. Thomas, I never knew about your clubfoot. Why didn’t you tell me?”
   She sat down on the arm of his chair, forcing him to swing around into a normal position. He didn’t answer, concentrating on his drink.
   “It’s not important,” said Cassi, “but I’m an expert on childhood afflictions. I find it reassuring that we shared such an experience. I think it gives us a special degree of understanding.”
   “I can’t remember anything about a clubfoot,” said Thomas. “As far as I know I never had one. The whole thing is some elaborate delusion of my mother’s. She wants you to be impressed by how she suffered bringing me up. Look at my feet: Do they look deformed?”
   Thomas took off his shoes and raised his feet.
   Looking down, Cassi had to admit both feet looked entirely normal. She knew Thomas had no problem walking and had been something of a college athlete. But she still wasn’t sure who had been telling the truth.
   “It seems incredible that your mother would make something like that up?” Her tone was more a question than a statement, but Thomas took it as a statement.
   Throwing down the medical journal, he leaped to his feet, nearly knocking Cassi to the floor. “Listen, I don’t care who you believe,” said Thomas. “My feet are fine, have always been fine, and I don’t want to hear anything more about a clubfoot.”
   “All right, all right,” said Cassi soothingly. With a professional eye she watched her husband, noting that his equilibrium was slightly off in that he’d overshoot with simple motions that required him to make subtle readjustments. And that wasn’t all. His speech was slightly slurred as well. Cassandra had noticed similar episodes over the previous months but she’d ignored them. He had every right to indulge himself with alcohol now and then, and she knew he liked Scotch. What surprised her was how short a time had passed since he’d fled from the dinner table. He must have tossed off quite a few drinks, one after another.
   More than anything, Cassi wanted Thomas to relax. If a discussion about a hypothetical clubfoot was going to upset him, she was perfectly willing to drop the subject forever if necessary. Sliding off the chair, she reached up to place her arm around his shoulder.
   He fended her off, defiantly taking another sip of Scotch. He looked contentious and eager to quarrel. At close range Cassi noted his pupils were constricted to mere dots of black in his bright blue irises. Suppressing her own irritation at being rejected, Cassi said: “Thomas, you must be exhausted. You need a good night’s sleep.” She reached up again and this time he permitted her to put her arm around his neck. “Come to bed with me,” she said softly.
   Thomas sighed but didn’t speak. He put down his half-finished drink and let Cassi lead him back down the hall to their bedroom. He started to unbutton his shirt, but Cassi pushed his hands away and did it for him. Slowly she undressed him, discarding his clothes in a careless heap on the floor. Once he was under the covers, she rapidly undressed herself, sliding in next to him. It was a delicious sensation to feel the coolness of the freshly laundered sheets, the comforting weight of the blankets, and the warmth of Thomas’s body. Outside the November wind howled and shook the Japanese wind chimes on the balcony.
   Cassi began by rubbing his neck and shoulders. Then she slowly worked her way down his body. Beneath her fingers she could feel him relax and respond to her. He stirred and enveloped her in an embrace. She kissed him and gently reached down between his legs. He was flaccid.
   The moment Thomas felt Cassi’s hand touch him, he sat up and pushed her away. “I don’t think it’s quite fair to expect that I’d be able to satisfy you tonight.”
   “I was interested in your pleasure,” said Cassi softly, “not my own.”
   “I’ll bet,” said Thomas viciously. “Don’t try any of your psychiatric bullshit on me.”
   “Thomas, it doesn’t matter if we make love or not.”
   Throwing his legs over the side of the bed, Thomas grabbed for his discarded clothes with jerky, uncoordinated motions. “I find that hard to believe.”
   Thomas went into the hall, slamming the door behind him with such force that the storm windows rattled in their frames.
   Cassi found herself engulfed in lonely darkness. The howling wind, which moments before had enhanced her sense of security, now did the opposite. The old fear of being abandoned haunted her. Despite the warmth of the blankets, Cassi shivered. What if Thomas left her? Desperately she tried to put the thought out of her mind because she could not bear the possibility. Maybe he had just been drunk. She recalled his lack of equilibrium and slurred speech. In the short time she’d spoken with Patricia, it didn’t seem possible that Thomas could have absorbed enough alcohol to cause such an effect, but when she thought about it, she had to admit that there had been several such episodes in the last three or four months.
   Rolling onto her back, Cassi stared at the ceiling where an outdoor lamp shining through the leafless tree outside created a pattern like a gigantic spider web. Frightened by the image, she turned on her side only to confront the same scary shadow on the wall across from the window. Was Thomas taking some kind of drug? Having admitted the possibility, she recognized that she’d been denying the signs for months. It was further evidence that Thomas was unhappy with her, that their life had drastically changed, and that he had changed.

   In the bathroom off his study, Thomas stared at his naked body in the mirror. Although he hated to admit it, he did look older. And more worrisome than that was his shriveled penis. To his own touch it felt almost numb, and the lack of sensation filled him with agonizing fear. What was wrong with his sexuality? When Cassi had been massaging him he’d felt the need for sexual release. But obviously his penis had had other ideas.
   It must have been Cassi’s fault, he reasoned halfheartedly, as he returned to the study and got into his clothes. Rescuing his drink, he sat at his desk and opened the second drawer on the right. In the very back, hidden by his stationery, were a number of plastic bottles. If he was going to sleep, he needed one more pill. Just one! Deftly he flipped one of the small yellow tablets into his mouth, then chased it down with his Scotch. It was amazing how quickly he felt the calming effect.

Four

   The next morning Cassi took her insulin and ate breakfast without any sign of Thomas. By eight she was concerned. Their usual schedule on Saturday was to leave by eight-fifteen so that Thomas could see his patients before Grand Rounds and Cassi could catch up on her own work.
   Putting down the article she’d been reading at her desk and tightening the belt on her robe, Cassi walked from the morning room down the hall and listened outside Thomas’s door. There were no sounds whatsoever. She knocked softly and waited. Still nothing. She tried the door. It was unlocked. Thomas was sound asleep with his alarm clock gripped in his hand. Evidently he’d turned it off and fallen directly back to sleep.
   Cassi walked over to him and shook him gently. There was no response. She shook him more forcibly and his heavy-lidded eyes opened, but he looked as if he didn’t recognize her.
   “I’m sorry to wake you, but it’s already after eight. You do want to go to Grand Rounds, don’t you?”
   “Grand Rounds?” answered Thomas with confusion. Then he seemed to understand. “Of course I want to go. I’ll be down for a bite in a few minutes. We’ll leave here in twenty at the most.”
   “I’m not going to the hospital today,” said Cassi as brightly as she could. “I’m not expected in psychiatry, and I have an enormous amount to read. I brought home an entire bag full of reprints.”
   “Suit yourself,” said Thomas, pushing himself up to a sitting position. “I’m on call tonight, so I’m not sure when I’ll be home. I’ll let you know later.”
   Cassi went down to the kitchen to make something for Thomas to eat in the car.
   Thomas sat on the edge of the bed while the room whirled around him. He waited until his vision cleared, feeling each pulse like a hammer in his head. He stumbled first to the desk where he got out one of his plastic containers. Then he made his way into the bathroom.
   Avoiding his image in the mirror, Thomas tried to get one of the small, orange triangular pills out of the container. It was no easy task, and it wasn’t until he’d dropped several that he got one into his mouth and washed it down. Only then did he venture a glance at his face. It didn’t look as bad as he feared nor as bad as he felt. With a bit more agility he took another pill, stepped into the shower, and turned on the water full blast.

   Cassi stood by the window in the living room watching as Thomas disappeared into the garage. Even through the glass she could hear the roar of the Porsche as it started. She wondered what it sounded like in Patricia’s apartment. The thought made her realize that she’d never visited Patricia; not once in the three years Cassi had been living there.
   She watched until Thomas’s Porsche had accelerated down the driveway and disappeared into the damp morning fog that hung over the salt marsh. Even after the car was out of sight, its low-frequency roar could be heard as Thomas shifted gears. Finally the noise vanished and the stillness of the empty house enveloped Cassi.
   Looking at her palms, Cassi noticed they were damp. Her first thought was that she was experiencing a mild insulin reaction. Then she realized it was nervousness. She was going to violate Thomas’s study. She’d always felt that trust and privacy were necessary parts of a close relationship, but she simply had to know if Thomas was taking tranquilizers or any other drugs. For months she’d been closing her eyes, hoping her marriage would improve. Now she knew she could not continue to wait passively any longer.
   As she opened the door to Thomas’s study, she felt like a burglar: a very bad burglar. Each little sound in the house made her jump.
   “My God,” said Cassi out loud. “You’re being an idiot!”
   Her own voice had a calming effect. As Thomas’s wife she had the right to enter every room in the house. Yet in many ways she still felt like a visitor.
   The study was in partial disarray. The sofa bed was still open, the covers piled in a heap on the floor. Cassi eyed the desk but then saw the open bathroom door. She pulled open the medicine cabinet. Inside were shaving gear, the usual litter of patented medicines, several old tooth-brushes, and some out-dated Tetracycline antibiotics. She looked through all the packages and containers. There was nothing remotely suspicious.
   As she was about to leave, her eye caught a flash of color on the white-tiled floor. Bending down, she found herself holding a small triangular orange pill stamped with SKF-E-19. It looked familiar, but she couldn’t place it. Back in Thomas’s study she scanned the bookshelves for a Physician’s Desk Reference. Not finding one, she walked back to the morning room and took out her own. Quickly she turned to the product identification section. It was Dexedrine!
   Holding the pill in her hand, Cassi stared out at the sea. There was a lone sailboat about a quarter mile out moving slowly through the swells. Watching it for a moment helped her organize her thoughts. She felt a weird mixture of relief and increased anxiety. The anxiety came from confirming her fear that Thomas might be taking drugs. The relief stemmed from the nature of the pill that she’d found—Dexedrine. Cassi could easily imagine an achiever like Thomas taking an occasional “upper” in order to sustain his almost superhuman performance. Cassi was aware of how much surgery Thomas did. She could understand how he could fall into the trap of taking a pill to sharpen his attention when he was otherwise exhausted. For Cassi it seemed to be in keeping with his personality. But as much as she tried to calm herself, she was still afraid. She knew the dangers of abusing Dexedrine and wondered how much she was to blame for Thomas’s need for the drug, and how long he’d been taking it.
   She put the innocent pill down on the desk and returned the PDR to the shelf. For a moment she was sorry she’d gone into Thomas’s study and found the pill. It would have been easier to ignore the situation. After all, it was most likely a temporary problem, and if she said something to Thomas, he would only get angry.
   “You’ve got to do something,” said Cassi, trying to build her resolve. As ridiculous as it seemed, the only person who exerted any kind of authority over Thomas’s life was Patricia. Although Cassi was reluctant to discuss the issue with anyone, at least she could expect Patricia to keep Thomas’s best interests at heart. Briefly weighing the advantages and disadvantages, she decided to discuss the situation with her mother-in-law. If Thomas had been abusing Dexedrine for a long time, someone should intervene.
   The first thing she had to do, Cassi decided, was to make herself presentable. Pulling off her terry robe and her nightgown, she went to the shower.

   Thomas enjoyed presenting cases at Grand Rounds. The entire departments of internal medicine and surgery attended, including residents and medical students. Today the MacPherson amphitheater was so full people had even been forced to sit on the steps leading up from the central pit. Thomas always drew a crowd even when, as today, he split the schedule with George.
   As Thomas finished his talk, which had been titled “Long-Term Follow-Up of Patients Undergoing Coronary Bypass,” the entire amphitheater broke into enthusiastic applause. The sheer volume of Thomas’s work was enough to impress anyone, and given his good results, the statistics seemed superhuman.
   When he opened up the floor for questions, someone from the upper tier yelled out that he’d like to know what kind of diet Thomas ate that gave him so much energy. The audience laughed heartily, eager for a morsel of humor.
   When the laughter died down, Thomas concluded by saying: “I believe from the statistics I’ve presented there can no longer be any residual doubt as to the efficacy of the coronary bypass procedure.”
   He gathered his papers and took a chair at the table behind the podium next to Dr. George Sherman.
   The topic of George’s presentation was “An Interesting Teaching Case.”
   Thomas inwardly groaned and glanced longingly at the exit. He had a splitting headache that had gotten progressively more intense after his arrival at the hospital. What a ridiculous topic, Thomas thought. He watched with mounting irritation as George made his way over to the podium and blew into the microphone to make sure it was on. As if that weren’t enough, he tapped it with his ring. Satisfied, he began to speak.
   The case was a twenty-eight-year-old man by the name of Jeoffry Washington who’d contracted acute rheumatic fever at age ten. He’d been a sick child at the time and hospitalized for an extended period. When the acute disease had run its course, the child had been left with a loud holosystolic heart murmur, indicating his mitral valve had been severely damaged. Over the years the problem gradually worsened to the point that an operation was needed to replace the damaged valve.
   At that point Jeoffry Washington was wheeled in and presented to the audience. He was a slight, callow-appearing Negro with angular, precise features, bright eyes, and skin the color of blond oak. He held his head back and stared up into the multitude of faces that were looking down at him.
   As Jeoffry was wheeled back out, Thomas’s and Jeoffry’s eyes happened to meet. Jeoffry nodded and smiled. Thomas returned the gesture. Thomas couldn’t help feeling sorry for the young man. Yet as tragic as his story was it was also quite common. Thomas had personally operated on hundreds of patients with similar histories.
   With Jeoffry gone, George returned to the podium. “Mr. Washington has been scheduled to have a mitral valve replacement, but during the work-up an interesting fact was uncovered. Mr. Washington had an episode of pneumocystic carini pneumonia one year ago.”
   An excited murmur rippled through the audience.
   “I suppose,” called George over the babble of voices, “that it is not necessary to remind you that such an illness suggested AIDS, or Acquired Immune Deficiency Syndrome, which was indeed found in this patient. As it turns out, Jeoffry Washington’s sexual preferences have placed him in that group of homosexual men whose life-style has apparently led to immuno-suppression.”
   Thomas now knew what George had meant by his comment in the surgical lounge the previous afternoon. He closed his eyes and tried to control his rising anger. Obviously Jeoffry Washington was an example of the kind of case that was taking OR slots and cardiac surgical beds away from Thomas’s patients. Thomas was not alone in his reservations concerning operating on Jeoffry. One of the internists raised his hand and George recognized him. “I would seriously question the rationale for elective heart surgery in light of the patient’s having AIDS,” said the internist.
   “That’s a good point,” said George. “I can say that Mr. Washington’s immunological picture is not grossly abnormal at present. He’s scheduled for surgery next week, but we will be following his helper T-cell and cytotoxic T-cell populations for any sudden decline. Dr. Sorenson of the department of immunology does not think the AIDS is an absolute contraindication for surgery at this time.”
   A number of hands popped up in the audience, and George began to call on them. The animated discussion took the conference over its normal time, and even after it was officially over, groups of people stood in clumps to continue talking.
   Thomas tried to leave immediately, but Ballantine had gotten up and blocked his way. “Good conference,” he beamed.
   Thomas nodded. All he wanted to do was get away. His head felt as if it were in a vise.
   George Sherman came up behind Thomas and clapped him on the back. “You and I really entertained them this morning. We should have charged admission.”
   Thomas slowly turned to face George’s smiling, self-satisfied face. “To tell you the honest truth, I think the conference was a goddamn farce.”
   There was an uncomfortable silence as the two men eyed one another in the midst of the crowd.
   “Okay,” said George at length. “I suppose you are entitled to your opinion.”
   “Tell me. Is this poor fellow, Jeoffry Washington, whom you paraded out here like some freak, occupying a cardiac surgical bed?”
   “Of course,” said George, his own ire rising. “Where do you think he’d be, in the cafeteria?”
   “All right, you two,” said Ballantine.
   “I’ll tell you where he should be,” snapped Thomas while he jabbed George in the chest with his index finger. “He should be on the medical floor in case something can be done about his immunological problem. Having already had pneumocystic carini pneumonia there’s a good chance he’ll be dead before he ever gets into a life-threatening cardiac state.”
   George knocked Thomas’s hand aside. “As I said, you’re entitled to your opinion. I happen to think Mr. Jeoffry Washington is a good teaching case.”
   “Good teaching case,” scoffed Thomas. “The man is medically ill. He should not be taking up a scarce cardiac surgical bed. The bed is needed for others. Can’t you understand that? It’s for this kind of nonsense that I have to keep my patients waiting, patients with no medical problems, patients who will be making real contributions to society.”
   George again knocked Thomas’s hand away. “Don’t touch me like that,” he snapped.
   “Gentlemen,” said Ballantine, stepping between them.
   “I’m not sure Thomas knows what the word means,” said George.
   “Listen, you little shithead,” snarled Thomas, reaching around Ballantine and grabbing a handful of George’s shirt. “You’re making a mockery of our program with the cases you’re dredging up just to keep the so-called teaching schedule full.”
   “You’d better let go of my shirt,” warned George, his face suffused with color.
   “Enough,” shouted Ballantine, pulling Thomas’s hand away.
   “Our job is to save lives,” said George through gritted teeth, “not make judgments about who is more worthy. That’s up to God to decide.”
   “That’s just it,” said Thomas. “You’re so stupid you don’t even realize that you are making judgments about who should live. The trouble is your judgment stinks. Every time you deny me OR space another potentially healthy patient is condemned to death.”
   Thomas spun on his heels and strode from the room.
   George took a deep breath, then adjusted his disheveled shirt.
   “God! Kingsley is such a prig.”
   “He is arrogant,” agreed Ballantine. “But he is such a damn good surgeon. Are you all right?”
   “I’m fine,” said George. “I must admit I came close to slugging him. You know, I think he’s going to be trouble. I hope he doesn’t get suspicious.”
   “In that sense his arrogance will be a help.”
   “We’ve been lucky. By the way, have you ever noticed Thomas’s tremor?”
   “No,” said Ballantine with surprise. “What tremor?”
   “It’s on and off,” said George. “I’ve noticed it for about a month, mainly because he was always so steady. I even noticed it today when he was doing his presentation.”
   “Lots of people are nervous in front of groups.”
   “Yeah,” said George, “but it was the same as when I was talking to him about the Wilkinson death.”
   “I’d rather not talk about Wilkinson,” said Ballantine, glancing around at the slowly emptying amphitheater. He smiled at an acquaintance. “Thomas is probably just tense.”
   “Maybe,” said George, not convinced. “I still think he’s going to be trouble.”

   Cassi dressed for her visit to Patricia as if it were the first time they were to meet. With great care she chose a dark blue wool skirt with a matching jacket to go over one of her high-necked white blouses. Just as she was about to leave, she noticed the atrocious state of her nails and thankfully postponed the visit while she removed her old polish and applied a new coat. When that was dry, she decided she didn’t like her hair, so she took it down and put it back up again.
   Finally having run out of reasons to delay, she crossed the courtyard between the house and the garage. It was freezing out. Ringing Patricia’s bell, Cassi could see her breath in the crisp air. There was no answer. Standing on tiptoes, she looked through a small window in the door, but all she could see was a flight of stairs. She tried the bell again, and this time saw her mother-in-law slowly descend the stairs and peer out through the glass. “What is it, Cassandra?” she called.
   Nonplussed that Patricia didn’t open the door, Cassi was silent for a minute. Under the circumstances she didn’t feel like shouting her reason for visiting. Finally she said: “I want to talk to you about Thomas.”
   Even with that explanation there was a long enough pause for Cassi to wonder if Patricia had heard her. Then several bolts snapped aside and the door opened. For a moment the two women eyed each other.
   “Yes,” said Patricia finally.
   “I’m sorry to bother you,” began Cassi. She let her sentence trail off.
   “You’re not bothering me,” said Patricia.
   “Could I come in?” asked Cassi.
   “I suppose,” said Patricia, starting up the stairs. “Be sure and close the door.”
   Cassi was glad to close the door on the cold, damp morning. Then she climbed after Patricia and found herself in a small apartment sumptuously furnished in Victorian red velvet and white lace.
   “This room is beautiful,” said Cassi.
   “Thank you,” said Patricia. “Thomas’s favorite color is red.”
   “Oh?” said Cassi, who had always thought Thomas partial to blue.
   “I spend a lot of time here,” said Patricia. “I wanted it comfortable and warm.”
   “It is that,” admitted Cassi, seeing for the first time a rocking horse, a kiddy car, and other toys.
   Patricia, as if following Cassi’s glance, explained: “Those are some of Thomas’s old toys. I think they’re rather decorative, don’t you?”
   “I do,” said Cassi. She thought the toys did have a certain appeal but looked a little out of place in the lavish setting.
   “How about some tea?” suggested Patricia.
   Suddenly Cassi realized that Patricia was as uncomfortable as she was.
   “Tea would be very nice,” said Cassi, feeling more at ease herself.
   Patricia’s kitchen was utilitarian, with white metal cabinets, an old refrigerator, and a small gas stove. Patricia put on the kettle and got out her china. From the top of the refrigerator she produced a wooden tray.
   “Milk or lemon?” asked Patricia.
   “Milk,” said Cassi.
   Watching her mother-in-law search for a creamer, Cassi realized how few visitors the older woman saw. With a touch of guilt Cassi wondered why they hadn’t become better friends. She tried to bring up Thomas’s problem, but the rift that had always existed between them silenced her. It wasn’t until they’d seated themselves in the living room with full teacups that Cassi finally got the courage to begin. “The reason I came over here this morning was to talk to you about Thomas.”
   “That’s what you said,” replied Patricia pleasantly. The old woman had warmed considerably and seemed to be enjoying the visit.
   Cassi sighed and put her teacup down on the coffee table. “I’m concerned about Thomas. I think he is pushing himself too hard and…”
   “He’s been that way since he was a toddler,” interrupted Patricia. “That boy was a hyperactive high achiever from the day he was born. And I tell you it was a twenty-four-hour-a-day job keeping him in line. Even before he could walk he was his own boss, and I had a devil of a time disciplining him. In fact from the day I brought him home from the hospital…”
   Listening to Patricia’s stories, Cassi realized exactly how central Thomas still was to the older woman’s world. It finally made sense to her why Patricia insisted on living where she did, even though it was so isolated. Watching her mother-in-law pause to sip her tea, Cassi noted how strongly Thomas resembled Patricia. Her face was thinner and more delicate, but there was the same aristocratic angularity.
   Cassi smiled. When Patricia put her cup back down, Cassi said, “Sounds like Thomas hasn’t changed much.”
   “I don’t think he’s changed at all,” said Patricia. Then with a laugh she added, “He’s been the same boy all his life. He’s needed a lot of attention.”
   “What I was hoping,” said Cassi, “is that you might help Thomas now.”
   “Oh?” said Patricia.
   Cassi could see the newly gained intimacy rapidly revert to the old suspiciousness. But she forged on. “Thomas listens to you and…”
   “Of course he listens to me. I’m his mother. What exactly are you leading up to, Cassandra?”
   “I have reason to suspect that Thomas may be taking drugs,” said Cassi. It was a relief to finally get it out. “I’ve suspected it for a few months but hoped the problem would just go away.”
   Patricia’s blue eyes became cold. “Thomas has never taken drugs,” she said.
   “Patricia, please understand me. I’m not just criticizing. I’m worried, and I think you might be able to help. He does what you tell him to do.”
   “If Thomas needs my help, then he should come and ask for it himself. After all, he chose you over me.” Patricia stood up. As far as she was concerned, the little tête-à-tête was over.
   So that was it. Patricia was still jealous that her little boy had grown up enough to take a wife.
   “Thomas didn’t choose me over you, Patricia,” said Cassi evenly. “He was looking for a different relationship.”
   “If it is such a different relationship, where are the children?”
   Cassi could feel her strength of will drain away. The whole issue of children was a sensitive and emotional one for her, since juvenile diabetics were cautioned against the risk of pregnancy. She looked down at her tea, realizing she never should have tried speaking to her mother-in-law.
   “There won’t be any children,” said Patricia, answering her own question. “And I know why not. Because of your illness. You know it’s a tragedy for Thomas to be childless. And he tells me you’ve been sleeping apart lately.”
   Cassi lifted her head, shocked that he would reveal such intimate matters. “I know Thomas and I have our problems,” she said. “But that’s not the issue. I’m afraid he is taking a drug called Dexedrine and that he has probably been taking it for some time. Even though he does it just to work harder, it can be dangerous both to him and his patients.”
   “Are you accusing my son of being an addict?” snapped Patricia.
   “No,” said Cassi, unable to explain further.
   “Well, I should hope not,” said Patricia. “Lots of people take a pill now and then. And for Thomas it is understandable. After all, he’s been driven from his own bed. I think your relationship is the real problem.”
   Cassi didn’t have the strength to fight back. She sat silently wondering if Patricia was right.
   “Furthermore I think you should go,” said Patricia, reaching across and taking Cassi’s cup.
   Without another word Cassi got up, descended the stairs, and let herself out.
   Patricia collected the teacups and carried them into the kitchen. She had tried to tell Thomas that marrying that girl was a mistake. If only he had listened.
   Back in the living room Patricia sat down at the telephone and called Thomas’s exchange. She left a message for him to call his mother as soon as possible.

   Thomas’s patients were inconveniently sprinkled on all three surgical floors. After Grand Rounds he’d taken the elevator to the eighteenth to work his way down. Normally on Saturdays, he liked to make rounds before the conference and before visiting hours. But today he’d arrived at the hospital late and consequently lost a lot of time reassuring nervous families. They would follow him out of the room and stand asking questions in the hall until in desperation he cut them off to examine his next patient only to be further delayed by that person’s relatives.
   It was a relief to reach the ICU where visitors were rarely allowed. As he pushed through the door he allowed himself to think about the regrettable episode with George Sherman. As understandable as his reaction was, Thomas was surprised and disappointed in himself.
   In the ICU, Thomas checked on the three patients he’d operated on the day before. All were fine. They’d been extubated and had taken something by mouth. EKGs, blood pressures, and all other vital signs were stable and normal. Mr. Campbell had had a few brief episodes of an irregular cardiac rhythm but that had been controlled when an astute resident found some unrelieved gastric dilation. Thomas got the fellow’s name. He wanted to compliment him next time he had the opportunity.
   Thomas walked over to Mr. Campbell’s bed. The man smiled weakly. Then he started to speak.
   Thomas bent over. “What did you say, Mr. Campbell?”
   “I have to urinate,” said Mr. Campbell softly.
   “You have a catheter in your bladder,” said Thomas.
   “I still have to urinate,” said Mr. Campbell.
   Thomas gave up. He’d let the nursing staff argue with Mr. Campbell.
   As he turned to leave, he glanced at the sorry case in the bed next to Mr. Campbell. It was one of Ballantine’s disasters. The patient had embolized air to the brain during the operation and now was no more than a living vegetable totally dependent on a breathing machine, but with the quality of the nursing care at the Memorial, he could be expected to live indefinitely.
   Thomas felt an arm on his shoulder. He turned and was surprised to find George Sherman.
   “Thomas,” began George. “I think it is healthy that we have disagreements if only because it might force us to examine our own positions. But it upsets me to think there has to be animosity.”
   “I was embarrassed at my own behavior,” said Thomas. That was as close as he could come to an apology.
   “I got a bit hot under the collar myself,” admitted George. He let his eyes leave Thomas’s face, noticing which bed Thomas had stopped at. “Poor Mr. Harwick. Talk about a shortage of beds. Here’s another one we could use.”
   Thomas smiled in spite of himself.
   “Trouble is,” added George, “Mr. Harwick is going to be here for a long time unless…”
   “Unless what?” asked Thomas.
   “Unless we pull the plug, as they say,” George smiled.
   Thomas tried to leave, but George gently restrained him.
   Thomas wondered why the man felt obligated to touch him all the time.
   “Tell me,” asked George. “Would you have the courage to pull the plug?”
   “Not unless I talked with Rodney Stoddard first,” said Thomas sarcastically. “What about you, George? You seem willing to do most anything to get more beds.”
   George laughed and withdrew his arm. “We all have our secrets, don’t we? I never expected you to say that you’d talk to Rodney. That’s a good one.” George gave Thomas another of his little taps and walked away, waving good-bye to the ICU nurses.
   Thomas watched him, then glanced back at the patient, thinking over George’s comments. From time to time a brain-dead patient was taken off his life support system, but neither doctors nor nurses acknowledged the fact.
   “Dr. Kingsley?”
   Thomas turned to face one of the ICU clerks.
   “Your service is on the line.”
   Giving Ballantine’s patient one last glance, Thomas walked over to the central desk wondering how he could get Ballantine to refer his difficult cases. Thomas was confident these “unanticipated” and “unavoidable” tragedies would not happen if he did the surgery.
   Thomas answered the phone with undisguised irritation. Invariably when the answering service looked for him it meant bad news. This time, however, the operator just said that he should call his mother as soon as he could.
   Perplexed, Thomas made the call. His mother never called him during the day unless it was something important.
   “Sorry to bother you, dear,” said Patricia.
   “What is it?” asked Thomas.
   “It’s about your wife.”
   There was a pause. Thomas could feel his patience evaporating.
   “Mother, I happen to be rather busy.”
   “Your wife paid me a visit this morning.”
   For a fleeting moment Thomas thought that Cassi might have mentioned his impotence. Then he realized that was absurd. But his mother’s next statement was even more alarming.
   “She was suggesting you were some kind of addict. Dexedrine, I think she said.”
   Thomas was so angry he could barely speak.
   “Wha-what else did she say?” he finally stammered.
   “I think that’s rather enough, don’t you? She said you were abusing drugs. I warned you about this girl, but you wouldn’t listen to me. Oh, no. You knew better…”
   “I’ll have to talk to you tonight,” said Thomas, disconnecting the line with his index finger.
   Still gripping the receiver, Thomas struggled to control his rage. Of course he took a pill now and then. Everybody did. How dared Cassi betray him by making a big deal of the fact to his mother? Abusing drugs! My God, an occasional pill didn’t mean he was an addict.
   Impulsively Thomas dialed Doris at home. She answered on the third ring out of breath.
   “How about a little company?” asked Thomas.
   “When?” asked Doris enthusiastically.
   “In a few minutes. I’m at the hospital.”
   “I’d love it,” said Doris. “I’m glad you caught me. I was just on my way upstairs.”
   Thomas hung up. He felt a twinge of fear. What if the same thing happened with Doris as happened last night with Cassi? Knowing it was better not to think about it, Thomas hurried through the rest of his rounds.
   Doris lived only a couple of blocks from the hospital on Bay State Road. As Thomas walked to her apartment, he could not stop thinking about what Cassi had done. Why would she want to provoke him like that? It didn’t make sense. Did she really think he wouldn’t find out? Maybe she was trying to get back at him in some illogical way. Thomas sighed. Being married to Cassi had not been the dream he’d envisioned. He’d thought she was going to be such an asset. So many people had swooned over her that he’d been convinced she was something special. Even George had been crazy for her, wanting to marry her after a handful of dates.
   Doris’s voice mixed with static greeted him over the intercom when he pushed her bell. He started up the stairs and heard her door open.
   “What a nice surprise,” she called as he rounded the first landing. She was dressed in a skimpy jogging outfit of shorts and a T-shirt that barely covered her navel. Her hair was loose and seemed incredibly thick and shiny.
   As she led him inside and closed the door, Thomas glanced around the apartment. He hadn’t been there for months, but not much had changed. The living room was tiny, with a single couch facing a small fireplace. At the end of the room was a bay window that overlooked the street. On the coffee table were a decanter and two glasses. Doris walked up to Thomas and leaned against him. “Did you want to dictate a little?” she teased, running her hands down his back. Thomas’s fears about his potency quickly vanished.
   “It’s not too early for a little fun, is it?” asked Doris, pressing herself against Thomas and sensing his arousal.
   “God, no,” said Thomas, pulling her down onto the couch and yanking off her clothes in an ecstasy of excitement and relief at his own response. As he plunged into her he comforted himself that the problem that he’d experienced the night before was Cassi’s, not his. It never occurred to him that he had yet to take a Percodan that day.

  The nurses in the surgical intensive care unit knew that problems, particularly serious problems, had an uncanny way of propagating themselves. The night had begun badly with the eleven-thirty arrest of an eleven-year-old girl who’d been operated on that day for a ruptured spleen. Luckily things had worked out well, and the child’s heart had begun beating again almost immediately. The nurses had been amazed at the number of doctors who had responded to the code. For a time there had been so many doctors that they’d been falling over each other.
   “I wonder why there are so many attendings in the house?” asked Andrea Bryant, the night supervisor. “It’s the first time I’ve seen Dr. Sherman here on a Saturday night since he was a resident.”
   “Must be a lot of emergency cases in the OR,” said the other RN, Trudy Bodanowitz.
   “That can’t be it,” said Andrea. “I spoke to the night supervisor there and she said that there were only two: an emergency cardiac case and a fractured hip.”
   “Beats me,” said Trudy, looking at her watch. It was just after midnight. “Do you want to take first break tonight?”
   The girls were sitting at the central desk finishing the paperwork engendered by the arrest. Neither was assigned to specific patients but rather manned the central station and performed the necessary administrative functions.
   “I’m not sure either of us is going to get a break,” said Andrea, looking around the large U-shaped desk. “This place is a mess. There’s nothing like having an arrest right after shift change to spoil routine.”
   The nurses’ station in the ICU rivaled the flight deck of a Boeing 747 for complicated electronic equipment. Facing the women were banks of TV screens giving constant read-outs on all the patients in the unit. Most were set within certain limits so that alarms would go off if the values strayed too far from normal. While the women were speaking, one of the EKG tracings was changing. As crucial minutes passed, the previously regular tracing began to look more and more erratic. Finally, the alarm went off.
   “Oh shit,” said Trudy as she looked up at the beeping oscilloscope screen. She stood up and gave the unit a slap with her hand, hoping that an electrical malfunction was the cause of the alarm. She saw the abnormal EKG pattern and switched to another lead, still hoping the problem was mechanical.
   “Who is it?” asked Andrea, checking for any evidence of frantic activities on the part of the nursing staff.
   “Harwick,” said Trudy.
   Andrea’s gaze quickly switched over to the bed of Dr. Ballantine’s OR disaster. There was no nurse in attendance, which was not unusual. Mr. Harwick had been exceptionally stable over the last weeks.
   “Call the surgical resident,” said Trudy. Mr. Harwick’s EKG was deteriorating even as Trudy watched. “Look at this, he’s going to arrest.”
   She pointed to the screen where Mr. Harwick’s EKG was showing typical changes before it either stopped or degenerated to ventricular fibrillation.
   “Should I call a code?” asked Andrea.
   The two women looked at each other.
   “Dr. Ballantine specifically said ‘no code,’ ” said Trudy.
   “I know,” said Andrea.
   “It always gives me an awful feeling,” said Trudy, looking back at the EKG. “I wish they wouldn’t put us in this position. It’s not fair.”
   While Trudy watched, the EKG line flattened out with just an occasional blip. Mr. Harwick had died.
   “Call the resident,” said Trudy angrily. She walked around the end of the ICU desk and approached Mr. Harwick’s bed. The respirator was still inflating and deflating his lungs, giving him the appearance of life.
   “Certainly doesn’t make you excited about having surgery,” said Andrea, hanging up the phone.
   “I wonder what went wrong. He was so stable,” said Trudy.
   Trudy reached out and flipped off the respirator. The hissing sound stopped. Mr. Harwick’s chest fell and was still.
   Andrea reached over and turned off the IV. “It’s probably just as well. Now the family can adjust and then go on with their lives.”

Five

   Two weeks had passed since Thomas learned of Cassi’s visit to his mother. While they had only fought briefly, the tension had been unbearable. Even Thomas had noted his increased dependency on Percodan, but he had to take something to allay his anxiety.
   As he ran down the hall late for the monthly death conference, he felt his pulse race.
   The meeting had already begun, and the chief surgical resident was presenting the first case, a trauma victim who had expired shortly after admission to the ER. The resident and intern had failed to notice warning signs that the sac covering the heart had been damaged and was filling with blood. Since no attending had been involved, the doctors happily raked the house staff over the coals.
   If the case had belonged to one of the private staff men, the discussion would have progressed very differently. The same points would have been made, but the physician would have been reassured that the diagnosis of hemopericardium was difficult and he’d done the best he could.
   Thomas had realized early in the game that the monthly death conference served more to relieve guilt than to punish, unless the offender was a resident. Lay people might have thought the death conference served as a kind of watchdog, but unfortunately such was not the case, as Thomas cynically observed. And the next case proved his point.
   Dr. Ballantine was mounting the podium to present Herbert Harwick. When he finished, an obese pathology resident quickly ran down the results of the autopsy, including slides of the individual’s brain, of which little remained.
   Mr. Harwick’s death was then discussed but with no mention that his trauma in the OR was the possible result of Dr. Ballantine’s inept surgery. The general feeling among the attendings was, “There but for the grace of God go I,” which was true to an extent. What made Thomas sick was that no one remembered that six months previously Ballantine had presented a similar case. Air embolism was a feared complication that at times occurred no matter what one did, but the fact that it occurred so often and at an increasing frequency to Ballantine was always ignored.
   Equally amazing, as far as Thomas was concerned, was that nothing was said about Harwick’s actual death in the ICU. As far as Thomas knew, the patient had been stable for an extended period of time before the sudden arrest. Thomas looked at the members of the audience and puzzled why they remained silent. It reconfirmed for him that bureaucracy and its committee method of dealing with problems was no way to run an organization.
   “If there’s no further discussion,” said Ballantine, “I think we should move on to the next case. Unfortunately I’m still in the dock.” He smiled thinly. “The patient’s name is Bruce Wilkinson. He is a forty-two-year-old white male who had suffered a heart attack and who had shown focally compromised coronary circulation, suggesting he was a good candidate for a triple bypass procedure.”
   Thomas straightened up in his chair. He remembered Wilkinson very clearly, particularly the night he’d attempted to resuscitate him. He could still see the surrealistic scene in his mind’s eye.
   Ballantine droned on, presenting the case with much too much detail. The chin of the surgeon sitting next to Thomas slumped onto his chest and his deep, regular breathing could be heard as far away as the podium. Finally Ballantine got to the end and said, “Mr. Wilkinson did extremely well postoperatively until the night of the fourth postoperative day. At that time he died.”
   Ballantine looked up from his papers. His face, in contrast to its expression when they were discussing the previous case, had assumed a defiant expression as if to say, “Try to find a mistake here.”
   A slight, well-dressed pathology resident got up from the first row and stepped behind the podium. He adjusted the small microphone nervously and bent over, thinking he had to speak directly into it. A high-pitched, irritating electronic sound resulted, and he backed away with apology.
   Thomas recognized the man. It was Robert Seibert, Cassi’s friend.
   As soon as Robert began his presentation of the pathology, all evidence of his nervousness disappeared. He was a good speaker, especially when compared with Ballantine, and he had organized his material so that only the significant points were mentioned. He showed a series of slides and pointed out that, although the patient had been described as having been deeply and grossly cyanotic at the time of death, there was no airway obstruction. He next presented a photomicrograph that showed that there was no alveolar problem in the lungs. Another series of slides showed there were no pulmonary emboli. Another series of photomicrographs was presented that showed there was no evidence that there had been a rise in left or right atrial pressure prior to death. The final series of pictures indicated that the bypasses were skillfully sutured in place and that there was no sign of recent myocardial infarction or heart attack.
   The lights came back on.
   “All this shows…” said Robert, pausing as if for effect, “that there was no cause of death in this case.”
   The audience responded with surprise. Such a statement was completely unexpected. There were even a few laughs as well as a comment from one of the orthopedic men who asked if this had been one of those cases that had awakened in the morgue. That inspired more laughter. Robert smiled.
   “Must have been a stroke,” said someone behind Thomas.
   “That is a good suggestion,” said Robert. “A stroke that shut down the breathing while the heart pumped the unoxygenated blood. That would cause deep cyanosis. But that would mean a brain-stem lesion. We went over the brain millimeter by millimeter and found nothing.”
   The audience was now silent.
   Robert waited for more comments, but there were none. Then he leaned forward and spoke into the microphone: “With permission I’d like to present another slide.”
   Cleverly he’d caught the imagination of the gathering.
   Thomas had an idea of what was coming.
   Robert switched off the lights, then switched on the projector. The slide showed a compilation of seventeen cases, containing comparable data on age, sex, and points of medical history.
   “I’ve been interested in cases such as Mr. Wilkinson for some time,” said Robert. “This slide is to show that his is not an isolated case. I have found four similar cases myself over the last year and a half. When I went back in the files, I found thirteen others. If you’ll notice, they have all had cardiac surgery. In each circumstance, no specific cause of death was found. I’ve labeled this syndrome sudden surgical death, or SSD.”
   The lights came back on.
   Ballantine’s face had turned bright red. “What do you think you are doing?” he spat at Robert.
   Under different circumstances Thomas might have felt sorry for Robert. His unexpected presentation did not fit within the rather narrow protocol for a death conference.
   Glancing around the room, Thomas saw many angry faces. It was an old story. Doctors did not like to have their expertise questioned. And they were reluctant to police their own.
   “This is a death conference, not a Grand Rounds,” Ballantine was saying. “We’re not here for a lecture.”
   “In discussing the case of Mr. Wilkinson, I thought it would be enlightening…”
   “You thought,” repeated Dr. Ballantine sarcastically. “Well, for your information you’re here as a consult. Did you have something specific to say when you presented this list of supposed sudden surgical deaths?”
   “No,” admitted Robert.
   Although Thomas preferred to stay silent at such meetings, he had to ask a question: “Excuse me, Robert,” he called. “Did all the seventeen cases have deep cyanosis?”
   Robert could not have been more eager to field a question from the audience. “No,” he said into the microphone. “Only five of the cases.”
   “That means that the physiologic cause of death was not the same in all these cases.”
   “That’s true,” said Robert. “Six had convulsions prior to death.”
   “That was probably air embolism,” said another surgeon.
   “I don’t think so,” said Robert. “First of all, the convulsions occurred three or more days after surgery. It would be hard to explain that kind of delay. Also when the brains were autopsied, no air was found.”
   “Could have been absorbed,” said someone else.
   “If there had been enough air to cause sudden convulsions and death,” said Robert, “then there should have been enough to see.”
   “What about the surgeons?” called the man behind Thomas. “Were any more heavily represented than others?”
   “Eight of the cases,” said Robert, “belonged to Dr. George Sherman.”
   A buzz of conversation broke out in the back of the room. George rose furiously to his feet as Ballantine nudged Robert from the podium.
   “If there are no further comments…” said Ballantine.
   George spoke out: “I think Dr. Kingsley’s comment was particularly cogent. By pointing out that there were different mechanisms of death in these cases, he indicated that there was no reason to try and relate the cases.” George looked over at Thomas.
   “Exactly,” said Thomas. He would have preferred to let George sink or swim on his own, but he felt obligated to respond. “It occurred to me that Robert had correlated the cases because of some similarity he saw in their deaths, but that didn’t seem to be the case.”
   “The basis of the correlation,” said Robert, “was that the deaths, particularly over the last several years, occurred when the patients were apparently doing well, and there was no anatomic or physiologic cause.”
   “Correction,” said George. “No cause was found by the department of pathology.”
   “It’s the same thing,” said Robert.
   “Not quite,” said George. “Maybe another pathology department would have found the causes. I think it’s more of a reflection on you and your colleagues than anything else. And intimating that there is something irregular about a series of operative tragedies on such a basis is irresponsible.”
   “Hear, hear,” shouted an orthopedic surgeon who began to clap. Robert quickly stepped down from the podium. There was an air of tension in the room.
   “The next death conference will be one month from today, January seventh,” said Ballantine, switching off the microphone and gathering his papers. He walked off the stage and over to Thomas.
   “You seemed to know that kid,” he said. “Who the hell is he?”
   “His name is Robert Seibert,” said Thomas. “He’s a second-year pathology resident.”
   “I’m going to have the kid’s balls in Formalin. Who does the little turd think he is, coming up here and putting himself up as our Socratic gadfly?”
   Over Ballantine’s shoulder, Thomas could see George making his way over to them. He was just as provoked as Ballantine.
   “I got his name,” said George menacingly, as if he were revealing a secret.
   “We already know it,” said Ballantine. “He’s only in his second year.”
   “Wonderful,” said George. “Not only do we have to put up with philosophers, but also smart-ass pathology residents.”
   “I heard there was a death this month in one of the cath rooms in radiology,” said Thomas. “How come it wasn’t presented?”
   “Oh, you mean Sam Stevens,” said George nervously, watching Robert leave the room. “Since the death occurred during the catheterization, the medical boys wanted to present it at their death conference.”
   While Thomas watched Dr. Ballantine and George fume, he wondered what they’d say if he told them that Cassi had been involved with the so-called SSD study. For everyone’s sake he hoped they wouldn’t find out. He also hoped that Cassi had had sense enough not to continue her association with Robert. All it could do was cause trouble.

   In a totally dark examination room, Cassi was lying flat on her back and could not have been more uncomfortable. She wasn’t in pain but close to it as she was forced to keep her eye still while Dr. Martin Obermeyer, chief of ophthalmology, shined an intensely bright light into her left eye. Worse than the discomfort was her fear of what the doctor would say. Cassi knew she’d been less than responsible about her eye problem. Desperately she hoped that Dr. Obermeyer would make some reassuring comment as he examined her. But he remained ominously quiet.
   Without so much as a word, he shifted the light into her good eye. The beam came from an apparatus that the doctor wore around his head, similar to a miner’s light, but more intricate. Although the light seemed bright in her left eye, when it shifted to the good eye the intensity was so great it was difficult for Cassi to believe it did not cause damage in and of itself.
   “Please, Cassi,” said Dr. Obermeyer, lifting the light beam and peering at her beneath the eyepieces of the instruments. “Please hold your eye still.” He pressed down with a small metal stylus.
   Irritative tears welled up, and Cassi could feel them spill over and run down the side of her face. She wondered how much longer she could stand it. Involuntarily she gripped the sheet covering the examining table. Just at the moment she thought she could no longer remain still, the light disappeared, but even after Dr. Obermeyer turned on the overhead lights, she could not see well. The doctor was a blur to her as he sat down at his desk to write.
   It concerned her that he was being so reticent. Obviously he was annoyed at her.
   “Can I sit up?” asked Cassi hesitatingly.
   “I don’t know why you ask my opinion,” said Dr. Obermeyer, “when you don’t follow any of my other suggestions.” The ophthalmologist didn’t bother turning around as he spoke.
   Cassi sat up and swung her legs over the side of the table. Her right eye was beginning to correct itself from the trauma of the bright light, but her vision remained blurry from the drops used to dilate her pupils. She watched Dr. Obermeyer’s back for a moment, digesting his comment. She’d expected him to be annoyed that she’d canceled her last appointment, but she hadn’t thought it would be this bad.
   Only after he finished writing and closed his chart did he turn back to Cassi. He was sitting on a low stool with wheels, and he glided over to face her.
   Cassi’s line of vision from her perch on the exam table was a good foot higher than the doctor’s. She could see the shiny area on the top of his head where his hair was thinning. He wasn’t the world’s best-looking man, with his full, heavy features and a deep line in the middle of his forehead. Yet the whole package was not unattractive. His face exuded intelligence and sincerity, two qualities that Cassi found appealing.
   “I think I should be frank,” he began. “There is no sign of the blood clearing from your left eye. In fact it appears as if there is new blood.”
   Cassi tried not to betray her anxiousness. She nodded as if she were listening to a discussion of another patient.
   “I still cannot visualize the retina,” said Dr. Obermeyer. “Consequently I do not know where the blood is coming from or if it is a treatable lesion.”
   “But the ultrasound test…” began Cassi.
   “It proved that the retina is not detached, at least not yet, but it cannot show where the bleeding is coming from.”
   “Perhaps if we waited a little longer.”
   “If it hasn’t cleared by now, it’s extremely unlikely that it will. Meanwhile we could lose the only chance we have to treat. Cassi, I’ve got to see the back of your eye. We must do a vitrectomy.”
   Cassi glanced away. “It can’t wait for a month or so?”
   “No,” said Dr. Obermeyer. “Cassi, you have already gotten me to postpone this longer than I wanted to. Then you canceled your last appointment. I’m not sure you understand the stakes here.”
   “I understand the stakes,” said Cassi. “It’s just not a good time.”
   “It’s never a good time for surgery,” said Dr. Obermeyer, “except for the surgeon. Let me schedule this thing and get on with it.”
   “I have to discuss it with Thomas,” said Cassi.
   “What?” questioned Dr. Obermeyer with surprise. “You haven’t told him about this?”
   “Oh yes,” said Cassi quickly. “Just not the timing.”
   “When can you discuss the timing with Thomas?” asked Dr. Obermeyer with resignation.
   “Soon. In fact tonight. I’ll be back to you tomorrow, I promise.” She slid off the table and steadied herself.
   Cassi was relieved to escape from the ophthalmologist’s office. Deep down she knew he was right; she should have the vitrectomy. But telling Thomas was going to be difficult. Cassi stopped at the end of the corridor on the fifth floor of the Professional Building, the same building where Thomas had his office. She stared out a window at the early December cityscape with its leafless tree-lined streets and densely packed brick buildings.
   An ambulance was screaming down Commonwealth Avenue, its lights flashing. Cassi closed her right eye, and the scene vanished to mere light. In a panic she reopened her eye to let the world back in. She had to do something. She had to talk with Thomas despite the difficulties they’d had since her visit to Patricia.
   Cassi wished that Saturday two weeks previously had never taken place. If only Patricia had not called Thomas. But of course that had been too much to ask. Expecting Thomas to come home angry, Cassi was shocked when he didn’t come home at all. At ten-thirty, Cassi had finally called Thomas’s exchange. Only then did she learn that Thomas had an emergency operation. She left word for him to call and waited up until two, finally falling asleep with book in hand and light on. Thomas finally came home on Sunday afternoon and, instead of screaming at her, refused to talk to her at all. With deliberate calm he moved his clothes into the guest room next to his study.
   For Cassi the “silent treatment” was an unbearable strain. What little conversation they did have was just chatter. Dinner was the worst, and several times Cassi, pleading a headache, took a tray to her room.
   After a week, Thomas had finally exploded in a rage. The triggering event had been insignificant; Cassi had dropped a Waterford glass on the tiled kitchen floor. As Thomas rushed over to her and started yelling, he accused Cassi of being deceitful and maneuvering behind his back. How dare Cassi go to his mother and accuse him of drug abuse?
   “Of course I’ve taken an occasional pill,” said Thomas, finally lowering his voice. “Either to help me sleep or keep me awake if I’ve been up all night. I dare you to name a single doctor who never took any of his own drugs!” He’d stabbed at her with his finger to make his point.
   Having taken an occasional Valium herself, Cassi was not about to contradict Thomas. Besides, intuition told her to be quiet and let Thomas vent his anger.
   In a more controlled tone Thomas asked her why in God’s name had she gone to Patricia. Cassi, of all people, knew how much his mother nagged him without anyone giving her such a potentially frightening subject.
   Sensing that Thomas had yelled himself out, Cassi tried to explain. She said that having found the Dexedrine, she’d been scared and had mistakenly thought that Patricia would be the best person to help if Thomas did have a problem. “And I never said you were an addict.”
   “My mother said you did,” snapped Thomas. “Who am I to believe?” He threw up his arms in disgust.
   Cassi didn’t answer although she was tempted to say that if Thomas didn’t know the answer after forty-two years of living with Patricia, he was never going to. Instead, Cassi apologized for jumping to conclusions after finding the Dexedrine and worse still for going to his mother. Tearfully she told him how much she loved him, silently acknowledging the fact she was more terrified of Thomas’s leaving her than she was of his possible drug abuse. She wanted their relationship to return to normal. If the strain had started with her complaining about her diabetes, Cassi decided she would shield Thomas from any knowledge of her problems. But now her eye was forcing the issue. The arrival of another screaming ambulance brought Cassi to the present. As much as she did not want to upset Thomas, she knew she had no choice. She could not go into the hospital and have an operation without telling him even if she somehow found the courage to do so. With terrible foreboding Cassi pushed the elevator button. She’d see Thomas now. Knowing herself, she was afraid that if she waited until they were at home that evening, she would not be able to broach the issue.
   Trying not to think anymore lest she change her mind, Cassi made her way down to Thomas’s office and pushed open the door. Fortunately there were no patients in the waiting room. Doris looked up from her typewriter and, as usual, turned back to her work without so much as acknowledging Cassi’s presence.
   “Is Thomas in?” asked Cassi.
   “Yes,” said Doris without interrupting her typing. “He’s with his last patient.”
   Cassi sat on the rose-colored couch. She couldn’t read because the blurring effect of the drops in her eye had not yet worn off. Since Doris didn’t look at Cassi, Cassi did not feel uncomfortable watching her. She noticed that the nurse had changed her hairstyle. Cassi thought that Doris looked better without the severity of her usual bun.
   Presently a patient emerged from the interior of the office. Brimming with good cheer, he smiled at Doris. “I feel terrific,” he said. “The doctor told me that I’m completely better. I can do whatever I like.”
   Pulling on his coat, he said to Cassi, “Dr. Kingsley’s the greatest. Don’t worry about a thing, young lady.” Turning to Doris he thanked her, blew her a kiss, and left.
   Cassi sighed as she got up. She knew Thomas was a great doctor. She wished she could elicit the kind of compassion that she believed he gave to his patients.
   Thomas was dictating when Cassi stepped into his office. “Thank you again, comma, Michael, comma, for this interesting case, comma, and if I can be of any further assistance in his management, comma, do not hesitate to call. Period. Sincerely yours, end dictation.”
   Clicking off the machine, Thomas swung around in his chair. He regarded Cassi with calculated indifference.
   “And to what do I owe the pleasure of this visit?” he asked.
   “I’ve just come from the ophthalmologist,” said Cassi, trying to control her voice.
   “That’s nice,” said Thomas.
   “I have to talk to you.”
   “It had better be short,” said Thomas, glancing at his watch. “I’ve got a patient in cardiogenic shock that I’ve got to see.”
   Cassi could feel her courage falter. She needed some sign that Thomas would not become irritated if she once again brought up her illness. But Thomas’s posture just suggested an aggressive nonchalance. It was as if he were daring her to cross some arbitrary line.
   “Well?” asked Thomas.
   “He had to dilate my pupils,” said Cassi, skirting the issue. “There’s been some deterioration. I wondered if we could go home a little earlier.”
   “I’m afraid not,” said Thomas, standing up. “I’m pretty sure the patient I’m seeing will need emergency surgery.” He slipped off his white jacket and hung it on the hook on the door leading to the examining room. “In fact, I may have to spend the night here in the hospital.”
   He said nothing about her eye. Cassi knew she had to bring up her own surgery, but she couldn’t. Instead she said, “You spent last night in the hospital. Thomas, you’re pushing yourself too hard. You need more rest.”
   “Some of us have to work,” said Thomas. “We can’t all be in psychiatry.” He pulled on his suit jacket, then stepped back to the desk to snap the tape out of the dictating machine