A pause. “They’re fine.”
“So things’re good at home?”
“Yeah. Sure.”
Dvorak nodded gravely. “Then you’re a lucky man.”
Face reddening, Sheehan stared down at the tox report. Cops see too much death, thought Dvorak, and they run around grabbing at all the highs in life they can get. Sheehan was struggling, a smart guy, a basically decent guy, dealing with the first glimpse of middle age in his mirror.
Lisa chose that moment to walk into the office, carrying two trays of microscope slides. She flashed Sheehan a smile and seemed taken aback when he simply looked away.
“Which slides are these?” asked Dvorak.
“Top tray’s liver and lung sections from Joseph Odette. Bottom tray has brain sections from Parmenter.” Lisa stole another glance at Sheehan, then pulled her dignity back together again. In a businesslike tone she said: “You just wanted H and E and PAS stains on the brain, right?”
“Did you do Congo-Red?”
“That’s in there too. Just in case.” She turned and walked out, pride intact.
After a moment, Sheehan left as well, a temporarily chastened Romeo.
Dvorak brought the trays of new slides back to the lab and turned on his microscope. The first slide was of Joey Odette’s lung. Smoker, he thought, focusing on the alveoli. No surprise; he’d already recognized the emphysematous changes at autopsy. He flipped through a few more lung sections, then moved onto the liver slides. Cirrhosis and fatty infiltration. A boozer, too. Had Joey Odette not shot himself in the head, either his liver or his lungs would have failed him eventually. There are many ways to commit suicide.
He dictated his findings, then set aside the Odette slides and reached for the next tray.
The first slide of Angus Parmenter’s brain appeared through the lens. The microscopic exam of brain sections was a routine part of the autopsy. This slide showed a section of cerebral cortex, stained a hot pink with periodic-acid-Schiff. He focused, and the field came sharply into view. For a full ten seconds he stared through the eyepiece, trying to make sense of what he was seeing.
Artifact, he thought. That must be the problem. A distortion of tissue from the fixing or staining process.
He took out the slide and put in another. Again he focused.
Again, everything looked all wrong. Instead of a uniform field of neuronal tissue stippled with occasional purple nuclei, this looked like pink and white froth. There were vacuoles everywhere, as though the brain matter had been eaten away by microsopic moths.
Slowly he lifted his head from the eyepieces. Then he looked down at his finger—the finger he’d cut with the scalpel. The laceration was healed now, but he could still see the fine line on the skin, where the wound had recently closed. I was working with the brain when it happened. I’ve been exposed.
The diagnosis would have to be confirmed. A neuropathologist consulted, electron microscopy performed, the clinical record reviewed. He should not be planning his own funeral quite yet.
His hands were sweating. He turned off the microscope and released a deep breath. Then he picked up the telephone.
It took his secretary only a moment to locate Toby Harper’s number in Newton. The phone rang six times before it was answered by an irritated “Hello?”
“Dr. Harper? This is Dan Dvorak at the ME’s office. Is this a good time to talk?”
“I’ve been trying to reach you all week.”
“I know,” he admitted. And could think of no excuse to give her.
“Do you have a diagnosis on Mr. Parmenter?” she asked.
“That’s why I’m calling. I need some more medical history from you.”
“You have his hospital record, don’t you?”
“Yes, but I wanted to talk to you about what you saw in the ER. I’m still trying to interpret the histology. What I need is a better clinical picture.”
Over the line, he heard what sounded like water running from a faucet, and then Toby called out: “No, turn it off! Turn it off, the water’s getting all over the floor!” The phone clattered down and there were running footsteps. She came back on the line. “Look, this isn’t a good time for me right now. Can we discuss this in person?”
He hesitated. “I suppose that’s a better idea. This afternoon?”
“Well, it’s my night off, but I have to make arrangements for a sitter. What time do you leave work?”
“I’ll stay as late as I need to.”
“Okay, I’ll try to get there by six. Where are you located?”
“Seven twenty Albany Street, across from City Hospital. It’ll be after hours, so the front door will be locked. Park around in back.”
“I’m still not sure what this is all about, Dr. Dvorak.”
“You’ll understand,” he said. “After you see the slides.”
10
It was nearly six-thirty when Toby pulled into the parking lot behind the two-story brick building at 720 Albany Street. She drove past three identical vans, each labeled on the side with COMMONWEALTH OF MASSACHUSETTS, CHIEF MEDICAL EXAMINER, and she parked in a stall near the building’s rear door. The rain, which had threatened all day, was finally beginning to fall in a gentle sprinkling that silvered the gloom. It was late October, and darkness fell so early these days; already she missed the long warm twilights of summer. The building looked like a crypt walled in by red brick.
She stepped out of the car and walked across the lot, head bent under the rain. Just as she reached the rear entrance, the door swung open. Her head snapped up in surprise.
A man was standing in the doorway, his tall frame silhouetted against the hall light. “Dr. Harper?”
“Yes.”
“I’m Dan Dvorak. They usually lock the doors by six, so I was watching for your arrival. Come in.”
She stepped into the building and wiped the rain from her eyes. Blinking against the light, she focused on Dvorak’s face, reconciling the mental image she’d formed from his telephone voice with the imposing man who stood before her. He was about as old as she’d expected, in his midforties, his black hair generously streaked with silver and tousled, as though he’d been nervously running his fingers through it. His eyes, an intense blue, were so deeply set they seemed to gaze at her from dark hollows. Though he did manage a small smile, she sensed it was forced; it flickered only briefly but attractively across his lips, and then was gone, replaced by an expression she could not quite fathom. Anxiety, perhaps. Worry.
“Most everyone’s gone home for the day,” he said. “So it really is as quiet as a morgue in here right now.”
“I tried to get here as soon as I could, but I had to make arrangements with the sitter.”
“You have children, then?”
“No, the sitter’s for my mother. I don’t like to leave her alone.”
They took the stairs up, Dvorak slightly in the lead, white lab coat flapping at long legs. “I’m sorry to ask you here on such short notice.”
“You’ve been refusing all my calls, and then suddenly you have to talk to me tonight. Why?”
“I need your clinical opinion.”
“I’m not a pathologist. You’re the one who did the autopsy.”
“But you examined him while he was still alive.”
He pushed through the stairwell door onto the second floor and started up the hall, moving with such nervous energy that Toby had to trot to keep up.
“There was a neurologist consulting on the case,” she said. “Did you talk to him?”
“He didn’t perform his exam until after the patient became comatose. By then there were few signs and symptoms to go on. Other than coma.”
“What about Wallenberg? He was the attending physician.”
“Wallenberg maintains it was a stroke.”
“Well, was it?”
“No.” He opened a door and flipped on the wall switch. It was an office furnished with a utilitarian steel desk, chairs, and a filing cabinet. The office of
a thoroughly organized man, thought Toby, looking at the neatly stacked papers, at the textbooks lined up on the shelf. The only personal touch to the office was an obviously neglected fern perched on the filing cabinet, and a photo on the desk. A teenage boy, shaggy-haired and squinting into the sunlight as he held up a prize trout. The boy’s face was a clone of Dvorak’s. She sat down in a chair by the desk.
“Would you like some coffee?” he asked.
“I’d rather have some information. What, exactly, did you find on autopsy?”
“On gross exam, nothing.”
“No evidence of a stroke?”
“Neither thrombotic nor hemorrhagic.”
“What about the heart? The coronaries?”
“Patent. In fact, I’ve never seen such a clean left anterior descending artery in a man his age. No evidence of infarction, fresh or otherwise. It wasn’t a cardiac death.” He sat down behind the desk, his gaze so intense on hers she had to force herself to maintain eye contact.
“Toxicology?”
“It’s been only a week. The preliminary screen shows diazepam and Dilantin. Both were given in the hospital to treat seizures.” He leaned forward. “Why did you insist on the autopsy?”
“I told you. He was the second patient I’d seen with that presentation of symptoms. I wanted a diagnosis.”
“Tell me the symptoms again. Everything you remember.”
She found it difficult to concentrate while those blue eyes were so intently focused on her face. She sat back, shifting her gaze to the stack of papers on his desk. She cleared her throat. “Confusion,” she said. “They both came into the ER disoriented to time and place.”
“Tell me first about Mr. Parmenter.”
She nodded. “The ambulance brought him in after his daughter found him stumbling around at home. He didn’t recognize her or his own granddaughters. From what I gathered, he was having visual hallucinations. Thought he could fly. When I examined him, I didn’t find any evidence of trauma. Neurologically, the only localizing sign seemed to be an abnormal finger-to-nose test. I thought at first it might be a cerebellar stroke. But there were other symptoms I couldn’t explain.”
“Such as?”
“He seemed to have some visual distortion. He had trouble judging how far away I was standing.” She paused, frowning. “Oh. That explains the midgets.”
“Excuse me?”
“He complained about midgets being in his house. I guess he was referring to his granddaughters. They’re about ten years old.”
“Okay, so he had distorted vision and cerebellar signs.”
“And there were seizures.”
“Yes, I saw you mentioned them in your ER notes.” He reached for a folder on his desk and opened it. She saw it was a photocopy of the patient’s Springer Hospital record. “You described a focal seizure of the right upper extremity.”
“The seizures recurred on and off during his hospitalization, despite anticonvulsants. That’s what the nurses told me.”
He flipped through the chart. “Wallenberg hardly mentions them. But I do see an order sheet here, for Dilantin. Which he signed.” He looked up at her. “Obviously, you’re correct about the seizures.”
Why wouldn’t I be? she thought with sudden irritation. Now she was the one who leaned forward. “Why don’t you just tell me which diagnosis you’re fishing for?”
“I don’t want to influence your memory of the case. I need your unbiased recollection.”
“Being straight with me would save us both a lot of time.”
“Are you pressed for time?”
“This is my night off, Dr. Dvorak. I could be home doing other things right now.”
He regarded her for a moment in silence. Then he sat back and released a heavy sigh. “Look, I’m sorry for being evasive, but this has shaken me up quite a bit.”
“Why?”
“I think we’re dealing with an infectious agent.”
“Bacterial? Viral?”
“Neither.”
She frowned at him. “What else is there? Are we talking parasites?”
He rose to his feet. “Why don’t you come down to the lab? I’ll show you the slides.”
They rode the elevator to the basement and stepped out into a deserted hallway. It was after seven now. She knew there had to be someone else on duty in the morgue, but at that moment, walking along the silent corridor, it seemed that she and Dvorak were utterly alone in the building. He led her through a doorway and flipped on the wall switch.
Fluorescent panels flickered on, the harsh light reflecting off gleaming surfaces. She saw a refrigerator, stainless steel sinks, a countertop with quantitative analysis equipment and a computer terminal. Lined up on a shelf were jars of human organs, suspended in preservative. The faint tang of Formalin hung in the air.
He crossed to one of the microscopes and flipped on the switch. It had a teaching eyepiece; they could both examine the field at the same time. He put a slide under the lens and sat down while he focused. “Take a look.”
She pulled up a stool. Bending her head close to his, she peered into the twin eyepiece. What she saw looked like white bubbles in a sea of pink.
“It’s been a long time since I took histology,” she admitted. “Give me a hint.”
“Okay. Can you identify the tissue we’re looking at?”
She flushed with embarrassment. If only she could rattle off the answer. Instead she was painfully aware of her ignorance. And of the silence stretching between them. With her face pressed to the eyepiece, she said: “I hate to admit it, but no, I can’t identify this.”
“It’s no reflection on your training, Dr. Harper. This slide is so abnormal the tissue is hard to recognize. What we’re looking at is a slide of Angus Parmenter’s cerebral cortex, PAS stained. The pink is background neuropil, with the nuclei stained purple.”
“What are all those vacuoles?”
“That was exactly my question. Normal cortex doesn’t have all those tiny holes.”
“Weird. It looks like my pink kitchen sponge.”
He didn’t respond. Puzzled, she raised her head and saw that he was looking at her. “Dr. Dvorak?”
“You saw it right away,” he murmured.
“What?”
“That’s exactly what it looks like. A pink sponge.” He sat back and rubbed his hand over his eyes. Under the harsh lab lights, she saw the lines of fatigue in his face, the shadow of dark beard. “I think we’re dealing with a spongiform encephalopathy,” he said.
“You mean like Creutzfeldt-Jakob disease?”
He nodded. “It would account for the pathologic changes on the slide. As well as the clinical picture. The mental deterioration. Visual distortion. Myoclonic jerks.”
“So they weren’t focal seizures?”
“No. I think what you saw was startle myoclonus. Violently repetitive spasms, set off by a loud noise. It can’t be controlled with Dilantin.”
“Isn’t Creutzfeldt-Jakob extremely rare?”
“One in a million. It tends to strike the elderly on a sporadic basis.”
“But there are clusters of cases. Last year, in England—”
“You’re thinking of mad cow disease. That seems to be a variant of Creutzfeldt-Jakob. Maybe it’s the same disease, we’re not really sure. The English victims got infected by eating beef with the bovine spongiform strain. That was a rare outbreak, and it hasn’t been seen since.”
Her gaze shifted back to the microscope. Softly she said, “Is it possible we have a cluster here? Angus Parmenter wasn’t the first patient I saw with those symptoms. Harry Slotkin was. He came in weeks before Parmenter did, with the same presentation. Confusion, visual distortion.”
“Those are nonspecific signs. You’d need an autopsy to confirm it.”
“That’s not possible with Mr. Slotkin. He’s still missing.”
“Then there’s no way to make the diagnosis.”
“They both lived in the same residential complex
. They could’ve been exposed to the same pathogen.”
“You don’t catch CJD the way you catch the common cold. It’s transmitted by a prion. An abnormal cellular protein. It requires direct tissue exposure. A corneal transplant, for instance.”
“Those people in England caught it from eating beef. Couldn’t it happen here? They could have shared a meal—”
“The American herd is clean. We don’t have mad cow disease.”
“How do we know that for certain?” She was intrigued now, feverishly pursuing this new line of thought. She remembered that night in the ER, when Harry had come in. Recalled the clang of the steel basin crashing to the floor, and then the sound of Harry’s leg rubbing against the gurney. “We have two men from the same housing complex. Presenting with the same symptoms.”
“Confusion isn’t specific enough.”
“Harry Slotkin had what I thought were focal seizures. Now I realize it might have been startle myoclonus.”
“I need a body to autopsy. I can’t diagnose Harry Slotkin without brain tissue.”
“Well, how certain are you of Angus Parmenter’s diagnosis?”
“I’ve sent the slides to a neuropathologist for confirmation. He’ll examine the sections under electron microscopy. The results may take a few days.” Quietly he added: “I’m just hoping I’m wrong.”
She studied him and realized she was seeing more than weariness in his face. What she saw was fear.
“I cut myself,” he said. “During the autopsy. While I was removing the brain.” He shook his head, gave a strangely ironic laugh. “I’ve cut open a thousand skulls. Worked on bodies with HIV, hepatitis, even rabies. But I’ve never cut myself. Then I get Angus Parmenter on the table, and it looks like natural causes. A weeklong hospital stay, no evidence of infection. And what do I do? I cut my finger. While I’m working on the goddamn brain.”
“The diagnosis isn’t confirmed. It could be artifact. Maybe the slides weren’t prepared correctly.”
“That’s what I keep hoping.” He stared at the microscope, as though regarding his mortal enemy. “I had my hands around the brain. I couldn’t have chosen a worse time to nick myself.”