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〃No doubts at all； eh； Doctor？〃 This time the interjection was Pearson's。 Previously the pathologist had been looking down at his papers。 Now he turned directly to face Bartlett。
For a moment Bartlett hesitated and Lucy thought： Something is wrong； the diagnosis was in error and Joe Pearson is waiting to spring the trap。 Then she remembered that whatever Pearson knew Bartlett knew also by this time； so it would be no surprise to him。 In any case Bartlett had probably attended the autopsy。 Most conscientious surgeons did when a patient died。 But after the momentary pause the younger man went on urbanely。
〃One always has doubts in these emergency cases； Dr。 Pearson。 But I decided all the symptoms justified immediate exploratory surgery。〃 Bartlett paused。 〃However； there was no perforated ulcer present； and the patient was returned to the ward。 I called Dr。 Toynbee for consultation； but before he could arrive the patient died。〃
Gil Bartlett closed his ring binder and surveyed the table。 So the diagnosis had been wrong； and despite Bartlett's outwardly calm appearance Lucy knew that inside he was probably suffering the torments of self…criticism。 On the basis of the symptoms； though； it could certainly be argued that he was justified in operating。
Now O'Donnell was calling on Joe Pearson。 He inquired politely； 〃Would you give us the autopsy findings； please？〃 Lucy reflected that the head of surgery undoubtedly knew what was ing。 Automatically the heads of departments saw autopsy reports affecting their own staff。
Pearson shuffled his papers； then selected one。 His gaze shot around the table。 〃As Dr。 Bartlett told you； there was no perforated ulcer。 In fact； the abdomen was entirely normal。〃 He paused； as if for dramatic effect； then went on。 〃What was present； in the chest； was early development of pneumonia。 No doubt there was severe pleuritic pain ing from that。〃
So that was it。 Lucy ran her mind over what had been said before。 It was true…externally the two sets of symptoms would be identical。
O'Donnell was asking； 〃Is there any discussion？〃
There was an uneasy pause。 A mistake had been made； and yet it was not a wanton mistake。 Most of those in the room were unfortably aware the same thing might have happened to themselves。 It was Bill Rufus who spoke out。 〃With the symptoms described； I would say exploratory surgery was justified。〃
Pearson was waiting for this。 He started ruminatively。 〃Well； I don't know。〃 Then almost casually； like tossing a grenade without warning： 〃We're all aware that Dr。 Bartlett rarely sees beyond the abdomen。〃 Then in the stunned silence he asked Bartlett directly； 〃Did you examine the chest at all？〃
The remark and the question were outrageous。 Even if Bartlett were to be reprimanded； it should e from O'Donnell； not Pearson； and be done in private。 It was not as if Bartlett had a reputation for carelessness。 Those who had worked with him knew that he was thorough and； if anything； inclined to be ultra…cautious。 In this instance； obviously； he had been faced with the need to make a fast decision。
Bartlett was on his feet； his chair flung back； his face flaming red。 〃Of course I examined the chest！〃 He barked out the words； the beard moving rapidly。 〃I already said the patient was in no condition to have a chest film； and even if he had〃
〃Gentlemen！ Gentlemen！〃 It was O'Donnell； but Bartlett refused to be stopped。
〃It's very easy to have hindsight； as Dr。 Pearson loses no chance to remind us。〃
From across the table Charlie Dornberger motioned with his pipe。 〃I don't think Dr。 Pearson intended〃
Angrily Bartlett cut him off。 〃Of course you don't think so。 You're a friend of his。 And he doesn't have a vendetta with obstetricians。〃
〃Really！ I will not permit this。〃 O'Donnell was standing himself now； banging with his gavel。 His shoulders were squared； his athlete's bulk towering over the table。 Lucy thought： He's all man； every inch。 〃Dr。 Bartlett； will you be kind enough to sit down？〃 He waited； still standing； as Bartlett resumed his seat。
O'Donnell's outward annoyance was matched with an inward seething。 Joe Pearson had no right to throw a meeting into a shambles like this。 Now； instead of pursuing the discussion quietly and objectively； O'Donnell knew he had no choice but to close it。 It was costing him a lot of effort not to sound off at Joe Pearson right here and now。 But if he did he knew it would make the situation worse。
O'Donnell had not shared the opinion of Bill Rufus that Gil Bartlett was blameless in the matter of his patient's death。 O'Donnell was inclined to be more critical。 The key factor in the case was the absence of a chest X…ray。 If Bartlett had ordered an upright chest film at the time of admission； he could have looked for indications of gas across the top of the liver and under the diaphragm。 This was a clear signpost to any perforated ulcer； therefore the absence of it would certainly have set Bartlett thinking。 Also； the X…ray might have shown some clouding at the base of the lung； which would have indicated the pneumonia which Joe Pearson had found later at the autopsy。 One or another of these factors might easily have caused Bartlett to change his diagnosis and improved the patient's chances of survival。
Of course； O'Donnell reflected； Bartlett had claimed the patient was too sick for an X…ray to be taken。 But if the man had been as sick as that should Bartlett have undertaken surgery anyway？ O'Donnell's opinion was that he should not。
O'Donnell knew that when an ulcer perforated surgery should normally be begun within twenty…four hours。 After that time the death rate was higher with surgery than without。 This was because the first twenty…four hours were the hardest； after that； if a patient had survived that long； the body's own defenses would be at work sealing up the perforations。 From the symptoms Bartlett had described it seemed likely that the patient was close to the twenty…four…hour limit or perhaps past it。 In that case O'Donnell himself would have worked to improve the man's condition without surgery and with the intention of making a more definitive diagnosis later。 On the other hand； O'Donnell was aware that in medicine it was easy to have hindsight； but it was quite another matter to do an emergency on…the…spot diagnosis with a patient's life at stake。
All of this the chief of surgery would have had brought out； in the ordinary way； quietly and objectively； at the mortality conference。 Indeed； he would probably have led Gil Bartlett to make some of the points himself； Bartlett was honest and not afraid of self…examination。 The point of the discussion would have been evident to everyone。 There would have been no need for emphasis or recriminations。 Bartlett would not have enjoyed the experience； of course； but at the same time he would not have been humiliated。 More important still； O'Donnell's purpose would have been served and a practical lesson in differential diagnosis impressed on all the surgical staff。
Now none of this could happen。 If； at this stage； O'Donnell raised the points he had had in mind； he would appear to be supporting Pearson and further condemning Bartlett。 For the sake of Bartlett's