“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.