A Case of Need: A Novel (7 page)

“She shaved herself,” Hendricks said.

“Probably,” Weston nodded. “Of course, that doesn’t rule in or out an operation. But it should be kept in mind.”

He proceeded with the autopsy, working smoothly and quickly. He measured the girl at five-four and weighed her at one-forty. Considering the fluid she had lost, that was pretty heavy. Weston wrote it on the blackboard and made his first cut.

The standard autopsy incision is a Y-shaped cut running down from each shoulder, meeting at the midline of the body at the bottom of the ribs, and then continuing as a single incision to the pubic bone. The skin and muscle is then peeled away in three flaps; the ribs are cut open, exposing the lungs and heart; the abdomen is widely incised. Then the carotid arteries are tied and cut, the colon is tied and cut, the trachea and pharynx are cut—and the entire viscera, heart, lungs, stomach, liver, spleen, kidneys, and intestine are removed in a single motion.

After that, the eviscerated body is sewn shut. The isolated organs can then be examined at leisure, and sections cut for microscopic examination. While the pathologist is doing this, the deaner cuts the scalp open, removes the skullcap, and takes out the brain if permission for brain removal has been obtained.

Then I realized: there was no deaner here.
⁷
I mentioned this to Weston.

“That’s right,” he said, “We’re doing this one by ourselves. Completely.”

I watched as Weston made his cut. His hands trembled slightly, but his touch was still remarkably swift and efficient. As he opened the abdomen, blood welled out.

“Quick,” he said. “Suction.”

Hendricks brought a bottle attached to a suction hose. The abdominal fluid—dark red-black, mostly blood—was removed and measured in the bottle. Altogether, nearly three liters were withdrawn.

“I wish we had the chart,” Weston said. “I’d like to know how many units they gave her in the EW.”

I nodded. The normal blood volume in an average person was only about five quarts. To have so much in the abdomen implied a perforation somewhere.

When the fluid was drained, Weston continued the dissection, removing the organs and placing them in a stainless-steel pan. He carried them to the sink and washed them, then examined them one by one, beginning at the top, with the thyroid.

“Peculiar,” he said, holding it in his hands. “It feels like fifteen grams or so.”

The normal thyroid weighed between twenty and thirty.

“But probably a normal variation,” Weston said. He cut it open and examined the cut surface. We could see nothing unusual.

Then he incised the trachea, opening it down to the bifurcation into the lungs, which were expanded and pale white, instead of their normal pink-purple.

“Anaphylaxis,” Weston said. “Systemic. Any idea what she was hypersensitive to?”

“No,” I said.

Hendricks was taking notes. Weston deftly followed the bronchi down into the lungs, then opened the pulmonary arteries and veins.

He moved on to the heart, which he opened by making two looping incisions into the right and left sides, exposing all four chambers. “Perfectly normal.” Then he opened the coronary arteries. They were normal too, patent with little atherosclerosis.

Everything else was normal until we got to the uterus. It was purplish with hemorrhagic blood, and not very large, about the size and shape of a light bulb, with the ovaries and fallopian tubes leading into it. As Weston turned it in his hands, we saw the slice through the endometrium and muscle. That explained the bleeding into the peritoneal cavity.

But I was bothered by the size. It just didn’t look like a pregnant uterus to me, particularly if the girl was four months’ pregnant. At four months, the fetus was six inches long, with a pumping heart, developing eyes and face, and forming bones. The uterus would be markedly enlarged.

Weston thought the same thing. “Of course,” he said, “she probably got some oxytocin
⁸
at the EW, but still, it’s damned peculiar.”

He cut through the uterine wall and opened it up. The inside had been scraped quite well and carefully; the perforation was obviously a late development. Now, the inside of the uterus was filled with blood and numerous translucent, yellowish clots.

“Chicken-fat clots,”
⁹
Weston said. That meant it was postmortem.

He cleaned away the blood and clots and examined the scraped endometrial surface carefully.

“This wasn’t done by a total amateur,” Weston said. “Somebody knew at least the basic principles of curettage.”

“Except for the perforation.”

“Yes,” he said. “Except for that.”

“Well,” he said, “at least we already know one thing. She didn’t do it to herself.”

That was an important point. A large proportion of acute vaginal hemorrhages are the result of women attempting self-abortion, with drugs, or salt solutions, or soaps, or knitting needles and other devices. But Karen couldn’t have done this kind of scraping on herself. This required a general anesthetic for the patient.

I said, “Does this look like a pregnant uterus to you?”

“Questionable,” Weston said. “Very questionable. Let’s check the ovaries.”

Weston incised the ovaries, looking for the corpus luteum, the yellow spot that persists after the ovum has been released. He didn’t find one. In itself, that proved nothing; the corpus luteum began to degenerate after three months, and this girl was supposedly in her fourth month.

The deaner came in and said to Weston, “Shall I close up now?”

“Yes,” Weston said. “You might as well.”

The deaner began to suture the incision and wrap the body in a clean shroud. I turned to Weston. “Aren’t you going to examine the brain?”

“No permission,” Weston said.

The medical examiner, though he demanded an autopsy, usually did not insist on brain examination unless the situation suggested possible neuropathy.

“But I would have thought a family like the Randalls, medically oriented …”

“Oh, J. D. is all for it. It’s Mrs. Randall. She just refuses to have the brain removed, absolutely refuses. Ever met her?”

I shook my head.

“Quite a woman,” Weston said dryly.

He turned back to the organs, working down the GI tract from esophagus to anus. It was completely normal. I left before he finished everything; I had seen what I wanted to see and knew that the final report would be equivocal. At least on the basis of the gross organs, they would be unable to say that Karen Randall was definitely pregnant.

That was peculiar.

¹
Position as an intern or resident, where one is an M.D. but not licensed to practice, and still completing education.

²
Formerly the most violent area in Boston was Scollay Square, but it was demolished five years ago to make way for government buildings. Some consider that an improvement; some a step backward.

³
The frequently bizarre cases mean that every doctor and surgeon has a backlog of strange stories. One surgeon is fond of telling how he was on the Accident Floor—the City’s EW—when two victims of an auto accident were brought in. One man had lost his leg at the knee. The other had massive crush injury to the chest, so bad that the degree of damage could not at first be ascertained from the heavy bleeding. On an X ray of the chest, however, it was seen that one man’s foot and lower leg had been rammed into the second man’s chest, where it was lodged at the time of admission.

⁴
Dead on arrival at hospital.

⁵
The seeping of blood to the lowest portions of the body after death. It often helps establish the position of the body.

⁶
Pelvic Inflammatory Disease, usually infection of the fallopian tubes by Neisseria gonococcus, the agent of gonorrhea. Gonorrhea is considered to be the most common infectious disease of mankind. Twenty percent of prostitutes are thought to be infected.

⁷
Deaner is a traditional term for the man who takes care of the dissecting room. It is an ancient term, dating back to the days when anatomy dissections were done by horse gelders and butchers. The deaner keeps the rooms clean, cares for the corpses, and aids in the dissection.

⁸
A drug to contract the uterus, useful for initiating birth and for stopping uterine bleeding.

⁹
See
Appendix I: Delicatessen Pathologists
.

I
HAVE TROUBLE BUYING LIFE INSURANCE
. Most pathologists do: the companies take one look at you and shudder—constant exposure to tuberculosis, malignancies, and lethal infectious disease makes you a very poor risk. The only person I know who has more trouble getting insured is a biochemist named Jim Murphy.

When he was younger, Murphy played halfback for Yale and was named to the All-East team. That in itself is an accomplishment, but it is amazing if you know Murphy and have seen his eyes. Murphy is practically blind. He wears lenses an inch thick and walks with his head drooping, as if the weight of the glass burdened him down. His vision is barely adequate under most circumstances, but when he gets excited or tight, he walks into things.

On the surface it would not seem that Murphy had the makings of a halfback, even at Yale. To know his secret, you have to see him move. Murphy is fast. He also has the best balance of anyone I know. When he was playing football, his teammates devised a series of plays especially designed to allow the quarterback to point Murphy in the proper direction and send him on his way. This usually worked, though on several occasions Murphy made brilliant runs in the wrong direction, twice charging over the goal line for a safety.

He has always been drawn to unlikely sports. At the age of thirty, he decided to take up mountain climbing. He found it very agreeable, but he couldn’t get insured. So he switched to sports-car racing and was doing very well until he drove a Lotus off the track, rolled it four times, and broke both clavicles in several places. After that, he decided he’d rather be insured than active, so he gave it all up.

Murphy is so fast he even speaks in a kind of shorthand, as if he can’t be bothered putting all the articles and pronouns into his sentences. He drives his secretaries and technicians mad, not only because of his speech, but also because of the windows. Murphy keeps them wide open, even in winter, and he is an unrelenting opponent of what he calls “bad air.”

When I walked into his lab in one wing of the BLI
¹
I found it filled with apples. There were apples in the refrigerators, on the reagent benches, on desks as paperweights. His two technicians, wearing heavy sweaters under their lab coats, were both eating apples as I entered.

“Wife,” Murphy said, shaking hands with me. “Makes a specialty. Want one? I have Delicious and Cortland today.”

“No, thanks,” I said.

He took a bite from one after polishing it briskly on his sleeve. “Good. Really.”

“I haven’t got time,” I said.

“Always in a rush,” Murph said. “Jesus Christ, always in a rush. Haven’t seen you or Judith for months. What’ve you been up to? Terry’s playing guard on the Belmont first eleven.”

He lifted a picture from his desk and held it under my nose. It showed his son in a football uniform, growling into the camera, looking like Murph: small, but tough.

“We’ll have to get together soon,” I said to him, “and talk about families.”

“Ummmm.” Murph devoured his apple with remarkable speed. “Let’s do that. How’s bridge game? Wife and I had an absolutely devastating time last weekend. Two weekends ago. Playing with—”

“Murph,” I said. “I have a problem.”

“Probably an ulcer,” Murph said, selecting another apple from a row along his desk. “Nervous guy I know. Always in a rush.”

“Actually,” I said, “this is right up your alley.”

He grinned in sudden interest. “Steroids? First time in history a pathologist’s interested in steroids, I bet.” He sat down behind his desk and propped his feet up. “Ready and waiting. Shoot.”

Murphy’s work concerned steroid production in pregnant women and fetuses. He was located in the BLI for a practical, if somewhat grisly, reason—he needed to be near the source of supply, which in his case was clinic mothers and the occasional stillbirths
²
assigned to him.

“Can you do a hormone test for pregnancy at autopsy?” I asked.

He scratched his head in swift, nervous, fluttery movements. “Hell. Suppose so. But who’d want to?”

“I want to.”

“What I mean is, can’t you tell at autopsy if she’s pregnant or not?”

“Actually, no, in this case. It’s very confused.”

“Well. No accepted test, but I imagine it could be done. How far along?”

“Four months, supposedly.”

“Four months? And you can’t tell from the uterus?”

“Murph—”

“Yeah, sure, it could be done at four months,” he said. “Won’t stand up in a courtroom or anything, but yeah. Could be done.”

“Can you do it?”

“That’s all we got in this lab,” he said. “Steroid assays. What’ve you got?”

I didn’t understand; I shook my head.

“Blood or urine. Which?”

“Oh. Blood.” I reached into my pocket and drew out a test tube of blood I had collected at the autopsy. I’d asked Weston if it was O.K., and he said he didn’t care.

Murph took the tube and held it to the light. He flicked it with his finger. “Need two cc’s,” he said. “Plenty here. No problem.”

“When will you let me know?”

“Two days. Assay takes forty-eight hours. This is post blood?”

“Yes. I was afraid the hormones might be denatured or something …”

Murph sighed. “How little we remember. Only proteins can be denatured, and steroids are not proteins, right? This’ll be easy. See, the normal rabbit test is chorionic gonadotrophin in urine. But in this lab we’re geared to measure that, or progesterone, or any of a number of other eleven-beta hydroxylated compounds. In pregnancy, progesterone levels increase ten times. Estriol levels increase a thousand times. We can measure a jump like that, no sweat.” He glanced at his technicians. “Even in
this
lab.”