Crisis (50 page)
Each took syringes and took the samples. Jack labeled his while Latasha did the same with hers.
"Let's see if there's an obvious right-to-left shunt," Jack said. "I keep thinking the cyanosis issue is going to prove important."
Carefully, Jack eased away the friable lungs to get a look at the great vessels. After a careful palpation, he shook his head. "Everything looks normal."
"The pathology is going to be in the heart," Latasha said with conviction.
"I think you are right," Jack agreed. He called Bill over and asked if there were any stainless pans or bowls they could use for the organs. Bill produced several from a cabinet below the embalming-room sink.
Proceeding as if they were accustomed to working together, Jack and Latasha removed the heart and lungs en bloc. While she held the pan, Jack lifted the specimen out of the chest and placed it inside. She put the pan down on the table beyond Patience's feet.
"Lungs look normal," Jack said. He rubbed his fingers over the lungs' surface.
"They feel normal, too," Latasha said as she gently prodded them in a few locations. "Too bad we don't have a scale."
Jack called Bill over and asked if a scale was available, but it wasn't.
"The weight feels normal to me," Jack said, hefting the block of tissue.
Latasha tried it but shook her head. "I'm not good at judging weights."
"I'm eager to get to the heart, but maybe we should first do the rest. What do you say?"
"Work first, play later: Is that your motto?"
"Something like that," Jack said. "Let's divide the job to speed things up. One of us could do the abdominal organs while the other does the neck dissection. For completeness' sake, I want to make sure the hyoid bone is intact, even though neither of us thinks strangulation was involved."
"If you are giving me a choice, I'll do the neck."
"You're on."
For the next half-hour they worked silently in their respective areas. Jack used the sink to wash out the intestines. It was in the large intestine that he found the first significant pathology. He called Latasha over and pointed. It was a cancer in the ascending colon.
"It's small, but it looks like it penetrated the wall," Latasha said.
"I think it has," Jack agreed. "And some of the abdominal nodes are enlarged. This is dramatic proof that hypochondriacs do get sick."
"Would that have been picked up by a bowel study?"
"Undoubtedly. If she'd had one. It's in Craig's records that she continually refused his recommendation to do it."
"So it would have killed her if she didn't have the heart attack."
"Eventually" Jack said. "How are you doing with the neck?"
"I'm about done. The hyoid is intact."
"Good! Why don't you get the brain out while I finish up with the abdomen? We're making excellent time." Jack glanced up at the wall clock. It was closing in on eight p.m., and his stomach was growling. "Are you going to take me up on the dinner offer?" he called to Latasha, who was on her way back to the table.
"Let's see what time it is when we finish," she called back over he shoulder.
Jack found a number of polyps throughout Patience's large intestine. When he was finished with the gut, he returned it to the abdominal cavity. "I do have to give Harold Langley credit. His job with Patience Stanhope would have made an ancient Egyptian embalmer proud."
"I don't have much experience with embalmed bodies, but the condition of this one is better than I expected," Latasha said as she plugged in the bone saw. It was a vibrating device designed to cut through hard bone but not soft tissue. She gave it a try. It produced a high-pitched whirring noise. She positioned herself at the head of the table and went to work on the cranium, which she had previously exposed by reflecting Patience's scalp down over her face.
Relatively immune to the racket, Jack palpated the liver, looking for metastases from the cancer in the colon. Not finding any, he made a series of slices through the organ, but it was seemingly clear. He knew that he might find some microscopically, but that would have to be at a later date.
Twenty minutes later, after the brain had been cleared of gross abnormality and a number of specimens from various organs were taken, the two pathologists turned their attention to the heart. Jack had cut away the lungs, so it was sitting in the pan by itself.
"It's like saving the best present for last," Jack said while gazing eagerly and intriguingly at the organ and wondering what secrets it was about to reveal. The size was about that of a large orange. The color of the muscle tissue was gray, but the greasy cap of adipose tissue was light tan.
"It's going to be like dessert," Latasha said with equal enthusiasm.
"Standing here looking at this heart reminds me of a case I did about half a year ago. It was a woman who collapsed in Bloomingdale's and whose heart couldn't be paced by an external pacemaker, just like Patience Stanhope."
"What did you find on that case?"
"A marked developmental narrowing of the posterior descending coronary artery. Apparently, a small thrombosis knocked out a good portion of the heart's conduction system in one fell swoop."
"Is that what you expect to find on this case?"
"It's high on my list," Jack said. "But I also think there is going to be some kind of septal defect causing a right-to-left shunt to account for the cyanosis." Then he added parenthetically, "What it's not going to tell us, I'm afraid, is why someone was so intent on us not finding out whatever it is we are about to learn."
"I think we're going to find widespread coronary disease and evidence of a number of previous small, asymptomatic heart attacks so that her conduction system was particularly at risk prior to the final event, but not compromised enough to show up on a standard ECG."
"That's an interesting thought," Jack said. He glanced across the table at Latasha, who continued to stare at the exposed heart. His respect for her kept growing. He just wished she didn't look nineteen. It made him feel over the hill.
"Remember, postmenopausal women have recently been shown to have different symptomatology than equivalent males when it comes to coronary heart disease! The case you just described is evidence of that."
"Stop making me feel ancient and uninformed," Jack complained.
Latasha made a gesture of dismissal with her gloved hand. "Yeah, sure!" she intoned with a chuckle.
"How about we make a little wager since neither one of us is in our home office, where such activity is frowned upon? I say it's going to be congenital and you say degenerative. I'm willing to put up five bucks in support of my idea."
"Whoa, big spender!" Latasha teased. "Five is a lot of cash, but I'll double you to ten."
"You're on," Jack said. After turning the heart over, he picked up a pair of fine forceps and scissors and went to work. Latasha supported the organ as Jack carefully traced and then opened the right coronary artery, concentrating on the posterior descending branch. When he'd traced it as far as the instruments would allow, he straightened up and stretched his back.
"No narrowing," he said with a combination of surprise and disappointment. Although he usually maintained an open mind diagnostically, for fear of being blinded by the positive finding, in this case he'd been quite certain of the pathology he'd encounter. It was the right coronary artery that supplied blood to most of the heart's conduction system, which had been knocked out by Patience Stanhope's heart attack.
"Don't despair yet," Latasha said. "The ten dollars is still in the balance. There's no narrowing, but I don't see any atheromatous deposits, either."
"You're right. It's perfectly clean," Jack agreed. He couldn't quite believe it. The entire vessel was grossly normal.
Jack turned his attention to the left coronary artery and its branches. But after a few minutes of dissection it was apparent the left was the same as the right. It was devoid of plaque and stricture. He was mystified and chagrined. After all he'd been through, it seemed a personal affront that there was no apparent coronary abnormality, either developmental or degenerative.
"The pathology has to be on the inside of the heart," Latasha said. "Maybe we'll see some vegetations on the mitral or aortic valve that could have thrown off a shower of thrombi that then cleared."
Jack nodded, but he was mulling over the probability of sudden cardiac death from a heart attack with no coronary artery disease. He thought it was extremely small, certainly less than ten percent, but obviously possible, as evidenced by the case in front of him. One thing about forensic pathology that he could always count on was seeing and learning something new.
Latasha handed Jack a long-bladed knife, waking him from a mini trance. "Come on! Let's see the interior."
Jack opened each of the heart's four chambers and made serial slices through the muscular walls. He and Latasha inspected the valves, the septa between the right and left sides of the heart, and the cut surfaces of the muscles. They worked silently, checking each structure individually and methodically. When they were finished, their eyes met across the table.
"The bright side is that neither of us is out ten dollars," Jack said, trying to salvage humor from the situation. "The dark side is that Patience Stanhope is keeping her secrets to herself. She was reputed to be less than cooperative in life, and she's staying in character in death."
"After hearing the history, I'm shocked that this heart appears so normal," Latasha said. "I've never seen this. I guess the answers are going to have to wait for the microscope. Maybe there was some kind of capillary disease process that involved only the smallest vessels of the coronary system."
"I've never heard of such a thing."
"Neither have I," Latasha admitted. "But she died of a heart attack that had to have been massive. We have to see pathology other than a small, asymptomatic colon cancer. Wait a second! What's that eponymous syndrome where the coronary arteries go into spasm?" She motioned to Jack as if she were playing charades, wanting him to come up with the name.
"I honestly have no idea. Now, don't spout some trivia that's going to make me feel inadequate."
"Prinzmetal! That's it." Latasha said triumphantly. "Prinzmetal angina."
"Never heard of it," Jack admitted. "Now you're reminding me of my brother-in-law, who's the victim in this disaster. He'd know it for sure. Can the spasm cause massive heart attacks? That's the question."
"It can't be Prinzmetal," Latasha said suddenly with a wave of dismissal. "Even in that syndrome, the spasm is associated with some stenoses of the vessel nearby, meaning there would be visible pathology, which we don't see."
"I'm relieved," Jack said.
"We have to figure this out one way or the other."
"That's my intention, but not seeing any cardiac pathology has me fooled and even embarrassed, considering all the fuss I've caused to do this autopsy."
"I have an idea," Latasha said. "Let's take all the samples back to my office. We can examine the heart under the stereo dissecting microscope and even do some frozen sections of the heart tis-sue to look at capillaries. The rest of the specimens will have to be processed normally."
"Maybe we should just go have some dinner," Jack said, suddenly wanting to wash his hands of the whole affair.
"I'll pick up some pizza on the way back to the office. Come on! We'll make it a party. There's one hell of a mystery here. Let's see if we can't solve it. We can even get a toxicology screen tonight. I happen to know the night supervisor at the lab at the university. He and I were an item a while back. Things didn't work out, but we're still acquaintances."
Jack's ears pricked up. "Run that by me again!" he said with disbelief. "We could get a toxicology screen done tonight?" Back in New York at the OCME, Jack was lucky to get one in a week.
"The answer is yes, but we'll have to wait until after eleven, when Allan Smitham begins his shift."
"Who's Allan Smitham?" Jack asked. The possibility of an immediate toxicology screen opened up another whole dimension of inquiry.
"We met in college. We took a lot of chem and bio classes together. Then I went to med school and he went to grad school. Now we work a few blocks apart."
"What about your beauty rest?"
"I'll worry about that tomorrow night. You have me hooked on this case. We have to save your brother-in-law from the evil lawyers."
20
NEWTON, MASSACHUSETTS THURSDAY, JUNE 8, 2006 9:05 P.M.
Alexis answered on the fourth ring. Jack had called her number and put his phone on speaker before placing it on the rent-a-car's front passenger seat. He was on his way from the Langley-Peerson Funeral Home to the Newton Memorial Hospital. He'd decided to make a short visit before the three-to-eleven shift left for the day in hopes of catching Matt Gilbert and Georgina O'Keefe. It had been an impulsive decision when he and Latasha left the funeral home after finishing up with the autopsy. She had said she was going to stop at her apartment briefly to feed the dog, drop off the fluid samples at the toxicology lab with a message for Allan to call as soon as he got in, and pick up a couple of pizzas at an all-night joint before meeting him in the parking lot of the medical examiner's office. She had given Jack the opportunity to tag along, but the window of opportunity had made him decide to stop at the hospital instead.