A slim, tanned man straightened and turned around from the body he had been peering into. He smiled. “Dr. Lane, nice to see you again.” His welcome was so warm that I felt my shoulders relax slightly. The knot which had been forming at the base of my neck began to dissolve.
I shook his hand calmly. “Dr. Pearman, how are you?”
“Fine. Thanks. Call me Walt.”
I nodded and smiled. “Call me Veronica.”
He paused. “I’d like your help with this girl. Her case appears to be quite unusual.” He had a quizzical look on his face as he gestured at the body in front of him, and I choked down a gag. It was no longer Sarah, but a gruesome lab experiment. This was why family and friends are never allowed to see the body once this process has been started, I thought, and just another indication that I was too involved in Sarah’s case. Autopsies did not ordinarily bother me. Once the pathologist is finished, the undertaker puts things back into a more presentable state for the funeral, but looking at what was before me, I had to wonder how.
I blew out a breath. I was by no means unfamiliar with autopsies, for all that I abhorred this one, and I resumed my professional demeanor. “Okay, shoot.”
“What medications did she take?” Pearman asked, moving around to stand by Sarah’s head.
Surely that was on the chart, I thought. “Let’s see. I believe that she was only on anti-depressants at the time of her admission. She has been on steroid therapy recently, as well as Rebif B prior to that to suppress her aberrant T-cells. They all failed, so I stopped them months ago. I just discontinued the prednisone steroid course about two weeks ago when she was in my office.” I took a deep breath and exhaled slowly.
“Did she have any skin conditions?” Pearman picked up a pen and the note pad on which he had been jotting down weights and numbers.
“She didn’t have any discrete skin conditions, but her nutrition status was very poor, and her nails were becoming weak and discolored. Her depression had progressed to the point that she didn’t want to eat much anymore. She told me that sometimes the only thing she would take in all day was hot chamomile tea because it seemed to relax her muscle spasms. I believe she took vitamins too, but her caloric intake was simply inadequate.”
“Has she ever been treated with Fowler’s solution?” He mumbled a little as he took notes.
“Fowler’s solution?” I repeated, surprised. “I’ve never treated her with Fowler’s solution. It was taken off of the market a long time ago because of the arsenic content.”
“Really?” He looked back up at me. It was his turn to be surprised. “Hmmm. Clearly I’m no clinician,” he said. “I’m afraid that I don’t keep up with the withdrawal of old drugs as well as I should since I don’t prescribe. So when was she diagnosed with multiple sclerosis?”
“About three or four years ago.” My stomach tightened. Here it came. “But she had been doing well until about six months ago, when she her symptoms worsened, and she had more frequent attacks.”
“What were her new attacks like?”
“Well, as you know, MS has a relapsing and remitting course of impairment and slow recovery of function, usually with some remaining tightness and weakness of the affected muscles.” I went a little overboard —going into detail like I was speaking in Grand Rounds— to prove to him that I did know what I was talking about. I felt entirely self-conscious and more than a little defensive about my diagnosis, although he had done nothing overtly to make me feel that way. “Ms. Summers was having particular trouble with her lower extremities, although both her arms and legs were affected. The weakness and numbness in her legs was not resolving well and she regained very little ground between attacks. Most recently it affected her right eye.”
“Did you run labs before she was admitted?”
“Of course. Blood counts, electrolytes and kidney function. She was slightly anemic, consistent with chronic disease, not much else. Her kidneys were still good.” When was he going to say it? That I had advanced the wrong treatment, blown everything, and killed the girl.
“You said that she was on anti-depressants. Was she suicidal?” Pearman continued methodically, without any change of pace.
I frowned. Where was he going with this? “No. In fact she told me that she didn't want to die. What did you find?” I had to know, the suspense was too much.
“Take a look again at her nails,” he gestured. “Do you recall the term Mee’s lines?”
“Yes.” I leaned forward and examined the mottled hand dispassionately. There were white streaks running across nine of the nails, all except for the left thumb.
“Those discolorations are Mee’s lines. The difference is that they run all the way across her nails, rather than making intermittent white lines as they would in malnutrition.” He went on as though his discourse were routine.
“My God! Arsenic ingestion?” My mouth fell open in shock.
“Exactly.” Pearman smiled in approbation of my recollection.
“The last time I heard of Mee’s lines, it was in an historical text about old time snake oil salesmen.” I shook my head. “Really? I would never have suspected arsenic.”
“You’re right, most physicians probably could not recall ever having heard the name Mee’s lines, much less what they signified. I can understand why you would not have identified the slight difference in her nails, particularly if Fowler’s solution has been off the market a long time. We took hair and nail samples, but those results won’t be back for a week or more. I can make a final statement about it then. However, based on her appearance, I would say that this has been going on between four and eight months. Take a look at these.”
I turned in the direction Dr. Pearman gestured. The long, black, stone counter behind us held her disembodied organs. He slipped on a pair of gloves and handed me the box so I could grab my own pair. Pearman first hefted the liver and held it out for me to examine. It was bloated and purple, heavier than any I have ever held. Then he pointed to the long snaking intestines, part of which had been slit open. They, too, were violaceous and the insides were blackened. The fecal odor emanating from them filled the room, but I thought that I could also smell fresh dirt, like turned earth after the rain. I wrinkled my nose trying to place it.
Pearman noticed and said, “It’s the metal that you smell. I believe there was a lot in her system at the time of death. That’s what coated the colon and turned it black. I would say that her death was acute-on-chronic arsenic poisoning. If she didn’t get Fowler’s solution from you, then I don’t know where it came from. A large amount like that at the end couldn’t be accidental. What I’m wondering is whether it’s possible that she committed suicide.”
“For eight months?” I tried to recall what else I had learned about arsenic in medical school. I had never encountered a case of arsenic ingestion in my entire career. It seemed the stuff of fiction, Miss Marple, Sherlock Holmes and Victorian England. These days arsenic was so well known, and so closely monitored, it was hard to imagine someone actually managing to die from it.
“Perhaps she was never able to get her nerve up to take enough until now?” Pearman guessed. He was not in forensic pathology.
“Considering the last several months, I can’t imagine her continuing to intentionally take it even in small amounts. I don’t suppose there is any other tonic out there she might have come across that she was taking to try to treat the MS, some homeopathic remedy? It would have to be something she was ordering from outside the country.” I shook my head. It didn’t seem like Sarah to self-medicate, or to have failed to tell me about it if she were. “Will you be able to tell where it came from?”
“No. At this point what’s in her system is broken down. There is no way I can think of to determine what the original compound was.” Pearman shrugged. “I’ll research it a bit of course,” he added, seeing my puzzled look.
I poked among the bits on the counter. Her kidneys looked fine; pink and healthy. That was about all that was. I loo
ked back up at him. “Where does this go from here?”
“I have to report all unnatural deaths. The police will investigate, and the Medical Examiner will be notified for an official forensic analysis. Although I can’t imagine that the ME will have much to add based on what I’m seeing. Hopefully, the police can turn up something that will shed a little more light on the situation.” Pearman’s face was bland. “I’ll let you know whatever they tell me.”
“Thanks. So, what about the investigation of her hospital care?”
“That’ll probably never happen. Her lungs showed no signs of allergic reaction to the chemotherapy, and her marrow and her blood were at only marginally subnormal levels, not low enough to be an unfavorable response to the chemotherapy. She never had time to respond to anything that you did. That was not what killed her.” He fingered the abdominal cavity, wiping up some of the black sludge on the side wall, and shook his head. “No, this was poisoning pure and simple.” He held up his gloved finger to show me before reaching for another specimen jar and rinsing his finger in it.
I breathed a shallow sigh of relief. Relief on my own account. “Thanks, Walt.”
“You’re quite welcome, Veronica. Thank you for coming down.” He walked with me back to the old elevator.
I heaved a bigger sigh of relief when the doors finally shut behind me.
Chapter 6
Following that encounter, I didn’t feel like going home. I was full of nervous energy. I decided to try to work it off at the office for a while on some paperwork. The office parking lot was empty when I rolled in. Not even Vickie’s car waited there. I relished the quiet of the office as I sat down at my desk. It was like the many nights before hiring Vickie when I had stayed to catch up on charts, no hustle and bustle, no jumping up to see the next patient— just the calm and tranquility of my own space.
A solitary ray of sun streamed in at an angle, lighting a shaft of dust motes over the desk. I watched the particles float down as I picked up a pile of charts to sign. Sarah Summers’ chart was at the top of the stack. I leafed through it, looking for any pattern that might suggest suicidal depression, not that I expected to find any. Arsenic poisoning? Self-doubt set in with a vengeance. Why hadn’t I seen that? Why hadn’t I suspected something new was going on rather than natural progression when she began to get worse. How could it have happened?
When she first started coming to my office, Sarah had been an energetic woman with short, bobbed, nearly black hair and a slim figure on which she typically wore short, swingy skirts. She had been upbeat in spite of the curves life had thrown her: loss of her parents at an early age, lack of funds to go to college, the desertion of her husband, and finally the diagnosis of MS. Her appearance was always polished when she came into the office. She always joked happily with the staff and with other patients in the waiting room, and often she brought me little gifts of baked goods or candy. Her disease had been practically unnoticeable until a few months ago.
Then, in the past six months, major portions of her body began to lose function. She lost her appetite and all but stopped eating. Her face became gaunt and her skin took on a dusty, tight appearance as though she had walked in out of a desert sandstorm. Sometimes her hair would be matted in the back because she didn’t have the strength to comb it, and her clothes were wrinkled. She frequently apologized to me for her appearance when she came in. It was obvious that this caused her as much distress as the physical pain.
In my opinion, her behavior was that of an ill patient, not the apathy of a suicidal patient. Of course she was depressed. Who wouldn't be? She was not nearly the eager soul she had been when I first began seeing her in residency. One day she came in crying over the pity she could see in people’s eyes, and the dirty looks she had started noticing around her at work where she had always felt comfortable. I had started her on anti-depressants. She said too, that she appreciated that I didn’t seem to pity her, that I seemed to understand without making her feel somehow less for it. But I suffered for her.
Remarkably, she never seemed to give up hope. On one occasion, I had brought up living wills, and Sarah had refused to discuss them. That was for dying people, she’d said. She was just sick.
***
The afternoon sky was dark and overcast, hastening dusk. It was just beginning to rain when Detective Jack Chapman pulled up to the visitor entrance of the hospital and parked under the protective awning. The soles of his shoes were wet and squeaked as he lumbered precariously across the marble floor. He looked around at the newly remodeled six story marble-lined atrium and suppressed a cough. The place looked like a mansion whose owners had too much money and too much time. He looked around and saw two grandmotherly volunteers at a desk near the gift shop. He was disoriented. He had not been summoned in by the pathologist in so long that he had missed all of the new construction.
“Excuse me. Since they revamped the place, how do I find Pathology?” He gave them his most congenial smile.
They both looked up, and then straightened and smiled. The woman on the left, with the blue tint to her curls, said, “Take those elevators to the basement floor. Take a right and follow the signs. It’s at the very end of the hallway. It’s really in the same place; just the route has changed.”
After twenty-nine years on the force, Chapman considered himself to be a great arbiter of justice. He had caught hundreds of criminals in his time. No one could outwit him. Not that the new chief recognized it.
He prepared himself for the case and the explanation he would hear from the pathologist. Of course, he always felt free to replace a proffered explanation with one of his own. The pathology report of suicide that had arrived at the station was only the most obvious explanation. There were always others.
He walked down a long, gray hall that looked dingy under the low lights even though it had been scrubbed that day. There were no windows, no source of light other than the scattered purplish fluorescent lights. He passed several doors, most unlabeled, and saw no other people along the hall. Nearly at the end of the hall, he was winded enough to stop for a breath. He stopped and rubbed his hands over his closely trimmed head— the gray, curly hair cut short to disguise the wave and the gray— as though his pause was merely to attend to grooming rather than breathlessness.
At the door labeled Department of Pathology in black painted letters, he smoothed his stubbly hair again as he breathed heavily for a few moments, and then proceeded into the suite. The room looked like any other office— carpeted cubicles all around with desks covered in papers. A few desks held microscopes, but otherwise there was no sign that this was a medical facility. No one was there to greet him.
The atmosphere made him shiver, but he knew that there was live company somewhere nearby. He walked through the maze of cubicles to a metal door bearing a large biohazard sign, and then hesitated in the doorway to the autopsy room. An athletic-looking, older gentleman was leaning over a cadaver. He recognized Dr. Pearman as he straightened and walked over, pulling off a pair of nitrile gloves.
Dr. Pearman stretched out his hand in greeting. “Detective Chapman, nice to see you. I’m afraid that my staff has already gone for the day.” He gestured into the perfect quiet of the room. He didn't mention that he had requested a police investigator first thing in the morning, just after Dr. Lane had left, and that he would be home like the rest of his staff if he hadn’t had to wait around.
“Hello, Dr. Pearman.” The detective took his hand, wondering how anyone could stand to be alone in a place like this. “What have we got today?”
Pearman’s face sobered, losing its apparent warmth, “Twenty-four year-old white female admitted a few days ago to the hospital for chemo. Died of apparent cardiac complications after the first dose, and family requested autopsy. The case appeared routine, but on exam, I found that the skin tone was off and the nails were abnormal, triggering hair and nail analysis. On dissection, there was auto-infarction, or tissue death of the intestines and liver, suggesting acute
poisoning and a very unpleasant death.”
“Could the chemotherapy have caused this?” asked Chapman as he looked around at the room behind Dr. Pearman. There was only a single stainless steel table with the partially covered cadaver lying on it. The hair stood up on his forearms, and he brushed it back down.
“No. The skin and nail changes are absolute signs of arsenic ingestion. I expect that the lab tests will confirm that. Nothing else could have done it.” Pearman leaned on a counter that still held a few bits of samples and jars of formaldehyde from the long day.
“Could all of her symptoms have come from arsenic?” asked the detective.
“I believe that many of them did. Chronic arsenic ingestion can mimic several nervous system diseases.”
“Why wasn’t this apparent while she was still alive?” Chapman asked.
“Arsenic is extremely rare and carefully monitored when it is used. It’s too uncommon to be considered in most cases.” Dr. Pearman stepped over to a workbench to find his notes. Chapman followed him and watched as he shuffled through requisitions for examination of other bodies. He pulled out his notes on Summers.
“What about the nails you mentioned?” asked Chapman.
“Very similar to nutritional deficiency. That’s what the doctor attributed it to." Pearman watched the detective shift uncomfortably, rubbing his forearms like he was cold.
Chapman asked, “So this was obvious to you, but not even under consideration by her regular physician?”
“Occam’s Razor.” Pearman shrugged. “The one disease that fits all of the symptoms is the disease the patient has,” said Dr. Pearman as he sat down in the reclining office chair that was so beat up that he kept it in the back. He tilted his head up as he studied Chapman.
“Meaning?” asked Detective Chapman. He wondered what pathologists thought about when they sized a person up. Did they consider what it would be like to cut through the fat in his abdomen to look at his insides? Did they wonder about the condition of his liver and make guesses as to how cirrhotic it might be?
Treating Murder: Book One of the Veronica Lane, M.D. series (medical thriller) Page 5
