A Case of Need

  “Who?”

  “Alan Zenner. He was a friend of hers.”

  “Uh-huh.”

  “He saw her, and she told him she was coming over here.”

  Angela and Bubbles exchanged looks. Bubbles said, “The dirty little—”

  “It’s not true?” I asked.

  “No,” Angela said tightly. “We didn’t see her.”

  “But he was positive—”

  “She must have changed her mind. She usually did, you know. Karen changed her mind so often you wondered if she had one.”

  Bubbles said, “Ang, listen…”

  “Get me another Coke, will you?”

  There was no mistaking the command in the voice. Bubbles got up meekly for another Coke.

  “Bubbles is nice,” Angela said, “but a little naive. She likes everything to be sweet and nice in the end. That’s why what happened to Karen bothers her so much.”

  “I see.”

  She stopped pacing and stood in front of me. Her body took on a rigidity that melted slowly into an icy calm. “Was there anything in particular you wanted to ask me?”

  “Just if you’d seen Karen.”

  “No. The answer is no.”

  I stood. “Well then, thank you for your time.”

  Angela nodded. I went to the door. As I left I heard Bubbles say, “Is he leaving?”

  And Angela said, “Shut up.”

  TWO

  SHORTLY BEFORE NOON I called Bradford’s office and was told that one of the staff was taking Dr. Lee’s case. The man was named George Wilson. My call was put through to him. Over the phone he sounded smooth and self-confident; he agreed to meet me for drinks at five, but not at the Trafalgar Club. We would meet at Crusher Thompson’s, a bar downtown.

  After that, I had lunch in a drive-in and read the morning papers. The story about Art’s arrest had finally broken, big, hitting all the front pages, though there was still no link to Karen Randall’s death. Along with the story was a picture of Art. There were dark, sadistic circles under his eyes. His mouth drooped in a sinister way and his hair was disheveled. He could have been any cheap hood.

  The stories didn’t say much, just a bare outline of the facts of his arrest. They didn’t have to say much: the picture said it all. In a way it was clever. You couldn’t move for a prejudicial pretrial publicity on the basis of an unflattering picture.

  After lunch I smoked a cigarette and tried to put it all together. I didn’t have much success. The descriptions I had heard of Karen were too conflicting, too uncertain. I had no clear picture of her, or what she might have done. Particularly what she might have done if she arrived in Boston for a weekend, pregnant, and needing an abortion.

  At one I called Murphy’s lab again. Murph answered the phone.

  “Hormones Unlimited.”

  “Hello, Murph. What’s the word?”

  “On Karen Randall?”

  “Murph, you’ve been doing homework.”

  “Not exactly,” he said. “The City just called. Weston was on the phone. Wanted to know if you’d brought in a blood sample.”

  “And what did you say?”

  “Yes.”

  “And what did he say?”

  “Wanted to know the results. I told him.”

  “What are the results?”

  “All the hormone and excretion metabolite levels are flat low. She wasn’t pregnant. Absolutely impossible.”

  “O.K.,” I said. “Thanks.”

  Murph had just put some life back into my theory. Not much, but some.

  “You going to explain all this, John?”

  “Not now,” I said.

  “You promised.”

  “I know,” I said. “But not now.”

  “I knew you’d do this to me,” Murph said. “Sarah will hate me.” Sarah was his wife. She thrived on gossip.

  “Sorry, but I just can’t.”

  “Hell of a thing to do to an old friend.”

  “Sorry.”

  “If she divorces me,” Murph said, “I’m naming you as co-defendant.”

  THREE

  I ARRIVED AT THE MALLORY PATH LABS AT THREE. The first man I ran into was Weston, who was looking tired. He gave me a lopsided smile of greeting.

  “What did you find out?” I said.

  “The findings are negative,” he said, “for pregnancy.”

  “Oh?”

  “Yes.” He picked up the folder containing the path protocol and thumbed through it. “No question.”

  “I called here earlier and was told the report was three months’ pregnancy.”

  Weston said carefully, “Whom did you talk with?”

  “A secretary.”

  “There must have been some kind of mistake.”

  “I guess,” I said.

  He handed me the folder. “Want to see the slides, too?”

  “Yes. I’d like to.”

  We walked to the pathologists’ reading room, a long room divided into individual cubicles, where the pathologists kept their microscopes and slides, and wrote up their autopsies.

  We stopped at one booth.

  “There it is,” Weston said, pointing to a box of slides. “I’ll be curious to have your opinion on them when you’re through.”

  He left me, and I sat down in front of the scope, switched on the light, and began work. There were thirty slides in the box, made from all the major organs. Six had been made from different parts of the uterus: I began with them.

  It was immediately clear that the girl was not pregnant. The endometrium was not hyperplastic. If anything, it appeared dormant and atrophic, with a thin proliferative layer, few glands, and decreased vascularity. I checked several other slides to be sure. They were all the same. Some contained thromboses from the scraping, but that was the only difference.

  As I looked at the slides I considered their meaning. The girl had not been pregnant, yet she had been convinced she was. Therefore her periods must have stopped. That could account for the dormant appearance of the endometrium. But what had caused the periods to stop? I ran through the differential in my mind.

  In a girl of this age, neurogenic factors came immediately to mind. The pressures and excitement of beginning school and moving to a new environment might have temporarily suppressed menstruation—but not for three months, and not with the associated signs: obesity, change in hair distribution, and so on.

  Then there were hormonal disorders. Adrenal virilizing syndromes, Stein-Leventhal, irradiation. All of them seemed unlikely for one reason or another, but there was one quick way to find out.

  I put the adrenal slide under the stage. There was good evidence of cortical atrophy, particularly in the cells of the zona fascicularis. The zona glomerulosa appeared normal.

  Rule out virilizing syndromes and adrenal tumor.

  Next I looked at the ovaries. Here the changes were striking. The follicles were small, immature, withered-looking. The whole organ, like the uterine endometrium, had a dormant appearance.

  Rule out Stein-Levanthal and ovarian tumor.

  Finally, I put the thyroid slide under the stage. Even under the lowest power, the atrophy of the gland was apparent. The follicles were shrunken and the lining cells were low. Clear hypothyroidism.

  That meant that the thyroid, adrenals, and ovaries were all atrophic. The diagnosis was clear, though the etiology was not. I opened the folder and read through the official report. Weston had done it; the style was brisk and direct. I came to the micro write-ups. He had noted the endometrium was low and aberrant-looking, but he had considered the other glands to be “of normal appearance, question mark early atrophic changes.”

  I shut the folder and went to see him.

  HIS OFFICE WAS LARGE, lined with books, and very neat. He sat behind an old, heavy desk smoking a briar pipe, looking scholarly and venerable.

  “Something wrong?” he asked.

  I hesitated. I had been wondering whether he had covered up, whether he had joined the oth
ers who were out to frame Art. But that was ridiculous; Weston couldn’t be bought, not at his age, not with his reputation. Nor was he particularly close to the Randall family. He would have no reason to falsify the report.

  “Yes,” I said. “I wondered about your micro diagnosis.”

  He puffed the pipe calmly. “Oh?”

  “Yes. I’ve just reviewed the slides, and they seem pretty atrophic to me. I thought perhaps—”

  “Well, John,” Weston said, chuckling, “I know what you’re going to say. You thought perhaps I’d want to review them.” He smiled at me. “I have reviewed them. Twice. This is an important postmortem and I did it as carefully as I know how. The first time I examined the slides, I felt as you did, that they seemed to show pan hypopituitarism affecting all three target organs—thyroid, adrenals, gonads. I felt that very strongly, so I went back to the gross organs. As you yourself say, the gross organs were not strikingly abnormal.”

  “It might have been recently acquired,” I said.

  “Yes,” he said, “it might. That’s what makes it so difficult. Then, too, we’d like a look at the brain, to check for evidence of neoplasm or infarction. But that’s not possible; the body was cremated this morning.”

  “I see.”

  He smiled up at me. “Sit down, John. It makes me nervous to have you standing like that.” When I was sitting, he said, “Anyway I looked at the gross, and then went back to the slides. This time I was less certain. I wasn’t fully convinced. So I checked some old cases of pan hypopit, reviewed the old slides, and finally looked at the Randall slides a third time. By then I felt I could not be certain of a diagnosis of pituitary dysfunction. The more I looked, the less certain I felt. I wanted some kind of corroboratory evidence—brain pathology, or X rays, or blood hormones. That was why I called Jim Murphy.”

  “Oh?”

  “Yes.” His pipe went out; he relit it again. “I suspected you’d taken the blood sample to do estradiol tests, and that you’d get Murphy to do it. I wanted to know if you’d also decided to have other hormone levels checked—TSH, ACTH, T4, anything that might help.”

  “Why didn’t you just call me?”

  “I did, but your lab didn’t know where you were.”

  I nodded. Everything he had said made perfect sense. I felt my body slowly relaxing.

  “By the way,” Weston said, “I understand some skull films of Karen Randall were taken a while back. Any idea what they showed?”

  “Nothing,” I said. “They were negative.”

  Weston sighed. “Pity.”

  “I’ll tell you something interesting though,” I said.

  “What’s that?”

  “They were ordered because she complained of blurring vision.”

  Weston sighed. “John, do you know the most common cause of blurring vision?”

  “No.”

  “Lack of sleep,” Weston said. He pushed the pipe to the side of his mouth and held it in his teeth. “What would you do if you were in my position? Make a diagnosis on the basis of a complaint which led to negative X rays?”

  “The slides are suggestive,” I reminded him.

  “But only suggestive.” He shook his head slowly. “This is already a confused case, John. I’m not going to make it more confused by throwing in a diagnosis I’m not sure about. After all, I may be called into court to defend it. I’d rather not stick my neck out. If the prosecution or the defense wants to find a pathologist to review the material and stick his neck out, that’s fine. The material is here for anyone to see. But I’m not going to do it. My years in the courtroom have taught me one thing, at least.”

  “What’s that?”

  “Never take a position unless you are certain it can be defended against any onslaught. That may sound like good advice to a general,” he said, smiling, “but then, a courtroom is nothing more than a very civilized war.”

  FOUR

  I HAD TO SEE SANDERSON. I had promised to see him, and now I needed his advice badly. But as I entered the lobby of the Lincoln Hospital, the first person I saw was Harry Fallon.

  He was slinking down a corridor, wearing a raincoat and hat pulled down over his forehead. Harry is an internist with a large suburban practice in Newton; he is also a former actor and something of a clown. I greeted him and he raised the brim of his hat slowly. His eyes were bloodshot and his face sallow.

  “I hab a code,” Harry said.

  “Who are you seeing?”

  “Gordon. The cheeb residend.” He took out a Kleenex and blew his nose loudly. “Aboud my bat code.”

  I laughed. “You sound like you’ve swallowed cotton.”

  “Thang you bery mugh.” He sniffled. “This is no labbing madder.”

  He was right, of course. All practicing doctors feared getting sick. Even small colds were considered bad for your image, for what is loosely called “patient rapport,” and any serious illness became a matter for the utmost secrecy. When old Henley finally developed chronic glomerulonephritis, he went to elaborate lengths to be sure his patients never found out; he would visit his doctor in the middle of the night, sneaking about like a thief.

  “It doesn’t sound like a bad cold,” I told Harry.

  “Hah. You thingh so? Listen to me.” He blew his nose again, a long, honking sound, somewhere between a foghorn and the death rattle of a hippopotamus.

  “How long have you had it?”

  “Du days. Du miberable, miberable days. My padends are nodicing.”

  “What are you taking for it?”

  “Hod toddies,” he said. “Besd thing for a virus. Bud the world is againsd me, John. Today, on tob ov my code, I got a tickud.”

  “A thickud?”

  “Yes. For double-barking.”

  I laughed, but at the back of my mind, something was bothering me, something I knew I should be remembering and thinking about, something I had forgotten and ignored.

  It was a strange and irritating feeling.

  I MET SANDERSON IN THE PATH LIBRARY. It’s a square room with lots of chairs, the folding kind, and a projector and screen. Path conferences are held here, in which autopsies are reviewed, and they are so frequent you can practically never get in to use the library books.

  On the shelves, in boxes, were autopsy reports for every person done in the Lincoln since 1923, the year we began to keep good records. Prior to that time, nobody had a very good idea of how many people were dying from what diseases, but as knowledge of medicine and the human body increased that information became vitally important. One proof of increased interest was the number of autopsies performed in 1923 all the reports filled one slim box—but by 1965 it required half a shelf for all the records. At present, more than seventy percent of all patients who died in the hospital were autopsied, and there was talk of microfilming the reports for the library.

  In one corner of the room was a portable electric coffeepot, a bowl of sugar, a stack of paper cups, and a sign that said, “5 cents a cup. Scout’s honor.” Sanderson was fussing with the pot, trying to get it to work. The pot represented an ancient challenge: it was said nobody was permitted to finish his path residency at the Lincoln until he had mastered its workings.

  “Someday,” Sanderson muttered, “I’m going to electrocute myself on this damned thing.” He plugged it in; crackling sounds were heard. “Me, or some other poor bastard. Cream and sugar?”

  “Please,” I said.

  Sanderson filled two cups, holding the pot at arm’s length. Sanderson was notoriously bad with anything mechanical. He had a superb, almost instinctive understanding of the human body and its functions of flesh and bone, but mechanical, steel, and electrical objects were beyond him. He lived in constant fear that his car, or his TV, or his stereo would break down; he regarded them all as potential traitors and deserters.

  He was a tall, powerfully built man who had once rowed stroke for the Harvard heavyweights. His forearms and wrists were as thick as most men’s calves. He had a solemn, thoughtful face
: he might have been a judge, or an excellent poker player.

  “Did Weston say anything else?” he asked.

  “No.”

  “You sound unhappy.”

  “Let’s say I’m worried.”

  Sanderson shook his head. “I think you’re barking up the wrong tree here,” he said. “Weston wouldn’t fake a report for anybody. If he says he was unsure, then he was.”

  “Maybe you should examine the slides yourself.”

  “I’d like to,” Sanderson said, “but you know that’s impossible.”

  He was right. If he showed up at Mallory and asked to see the slides, it would be taken as a personal insult by Weston. That kind of thing just wasn’t done.

  I said, “Maybe if he asked you…”

  “Why should he?”

  “I don’t know.”

  “Weston has made his diagnosis and signed his name to it. The matter closes there, unless it comes up again during the trial.”

  I felt a sinking feeling. Over the past days, I had come to believe very strongly that there must not be a trial. Any trial, even an acquittal, would seriously damage Art’s reputation, his standing, and his practice. A trial had to be prevented.

  “But you think she was hypopit,” Sanderson said.

  “Yes.”

  “Etiology?”

  “Neoplasm, I think.”

  “Adenoma?”1

  “I imagine. Maybe craniopharyngioma.”

  “How long?”

  “It couldn’t be very long,” I said. “X rays four months ago were normal. No enlargement or erosion of the sella turcica. But she did complain of vision trouble.”

  “What about pseudotumor?”

  Pseudotumor cerebri is a disorder of women and young children. Patients get all the symptoms of a tumor, but don’t actually have one. It is related to withdrawal of steroid therapy; women sometimes get it when taking birth-control pills. But as far as I knew, Karen wasn’t taking pills. I told Sanderson.

  “Too bad we don’t have slides of the brain,” he said.

  I nodded.

  “On the other hand,” Sanderson said, “an abortion was performed. We can’t forget that.”