Deficiency

TWO

Dr. Hyman Templeman pressed his lips together and squinted at Terri as if the sunlight coming through the opened pale blue Venetian blinds in his private office reflected too brightly off her face. Templeman's medical practice was located in his large home on Main Street, Centerville. It was a Queen Anne --

style Victorian house with a steeply pitched irregularly shaped roof, a dominant front-facing gable, and one side-facing gable. It had patterned white shingles and cutaway bay windows with Wedgwood blue shutters. The asymmetrical facade had a full-width, one-story-high porch that extended along both side walls. In its day it was one of the most expensive homes in the area. Now it was a remarkably well-kept historic whose spindle work detailing drew appreciative eyes.

"They just don't make houses like this anymore," people would say. And patients would add, "Nor do they make doctors like Hyman Templeman." The two-story building contained fourteen rooms. Hyman and his wife Estelle utilized the rear and the upstairs for living quarters, which was far more space than the two of them now needed. Their three children were all married and gone, two living in California and one in Westchester. The front five rooms, including a relatively recently built waiting room, were dedicated to Hyman's medical practice. He had an X-ray room, three examination rooms, and a small lab.

The structure didn't have much land around it, but it did have a long front lawn that unfolded smoothly toward the street. There was never enough parking space around or near his offices, but the village police had an unwritten understanding that they wouldn't ticket the cars of patients parked at expired meters. Parking was enforced only during the summer months anyway, and just as in most small resort communities, the recognizable cars belonging to residents enjoyed a special dispensation.

"I haven't seen a case of Frank scurvy since I served in the army medical corps," Hyman remarked. "And that was in the South Pacific. Never seen one around here. Why even the occasional stump jumpers and rednecks who come down from the hills don't have symptoms that bad. Frank scurvy is rare in the modern world, but the occurrence of petechiae, spongy gums, and tendency to bleed, usually with other evidences of nutritional deficiencies, suggests the possibility of scorbutic purpura."

"I know how unusual all this is, Hyman, but if you saw her..."

"Of course, I've heard of women who have gone on one or another of these fad diets denying themselves necessary nutrition. And you are aware, of course, that patients with gastrointestinal disease, especially those on an ulcer diet consisting chiefly of milk, cream, cereals, and eggs, develop secondary deficiencies. Infections increase the physiologic requirements for vitamin C and people with poor dietary habits are likely to precipitate the appearance of symptoms."

"I don't know whether or not she was on some fad diet, of course," Terri said,

"or if she was suffering from an ulcer..."

"Well, the Thorndykes have been my patients for years. I never treated Paige for anything like that." He shook his head. "We'll have to wait for the autopsy report to confirm it all," Hyman said sitting back in his high back, dark brown, wide-lapped leather chair. The mahogany arms were worn where he would run his palms up and down while he thought deeply or spoke intensely. It was a nervous habit Terri had noticed. What she didn't know was that it, along with some other chronic gestures, was growing more and more pronounced as Hyman approached his mid-seventies.

He was a tall, lean man with dark eyes and a dark complexion that made his crown of white hair that much more distinct. He had a long, thin nose, but a strong mouth with full lips and a hard, sharp jaw. Patients were usually set at immediate ease by his fatherly smile, a soft movement in his cheeks, and a radiant light around his eyes. They felt his compassion and concern and were reassured by his confidence and wisdom.

Terri knew it took years to develop the physician's demeanor, especially the demeanor of a man like Hyman Templeman. She longed for the time when she would finally not have to wonder if the patient had any faith in her diagnosis and prognosis. No one need be arrogant and overconfident, but a doctor had to emit assurance and firm purposes.

"I saw a lot of scurvy in infants while I was stationed in the Philippines." He shook his head. "Such an unnecessary thing and the poor little things -- you know," he said lifting his long right hand with its puffy fingers, "angular enlargements of the costochondral junctions of the ribs, swelling of the extremities over the ends of the long bones, swollen hemorrhagic gums surrounding erupting teeth..." His body shook as if an ice cube had been dropped down the back of his neck.

"You know there are things that deplete vitamins -- alcohol, of course, antibiotics, anticonvulsants, antihistamines, even aspirin -- but can you imagine the intake of one or more of these substances one would have to undergo to achieve this serious a condition?" he muttered.

She shook her head.

"In any case, what I really don't understand," Terri said, "is she not realizing she was this sick. Manifest scorbutic symptoms are almost always preceded by weakness, irritability, muscle aches and pains, and weight loss." Hyman shrugged.

"She might have attributed all that to her fad diet," he suggested.

"Um. But you would think bleeding gums, gingivitis, loose teeth would have frightened her into stopping it."

Hyman shook his head.

"I've seen a lot of craziness lately. Just last week, they rushed Mrs. Menkos in with a palpitating heart. She had been living on celery stalks and diet pills. She was losing hair, too. What about anorexia?" Hyman asked.

"That's the thing, Hyman. Paige Thorndyke didn't look anorexic to me. She was undernourished, but not really underweight."

He shook his head and then looked at his watch.

"Let's call," he said. "If Julie's on duty, he'll skip the protocol and give us the findings."

He leaned forward and lifted the receiver of the brass phone. Terri remembered sitting in this office nearly ten years ago to talk to Hyman Templeman about her ambitions. He still had that wonderful painting hanging behind his desk. It was a picture of a doctor making a house call and putting the stethoscope on his own chest to show the frightened child it was nothing. Terri had accompanied her grandmother, who had to have a routine examination, and while they waited for the nurse to help her get dressed, Hyman had invited her in to discuss her plans. He knew she wanted to be a doctor. In Centerville, everyone knew everyone else's business; sometimes before he or she knew it. Of course, Terri's parents had been bragging about her and, on more than one occasion, had told Hyman about her ambitions.

Funny, she thought, how everything looked so much bigger to her in those days. Hyman's dark oak desk had seemed enormous, as well as the office itself. Even the examination rooms were bigger in her eyes. Or was it that she was so much smaller? Regardless of her accomplishments and her association with Hyman Templeman, he still loomed larger than life in so many ways. The family doctor remained an icon in America, she thought, whether he or she deserved the reverence or not. She wondered, especially at this moment, if that veneration wasn't as much a liability as it was an asset. They expect miracles, and all we can offer is scientific knowledge and some medical skill. There certainly wasn't very much she could do for Paige Thorndyke last night, she concluded sadly.

"Julie," Hyman said when he had reached the morgue, "Hyman." Only someone with Hyman Templeman's standing in the medical community could slip past the hospital bureaucracy so smoothly, Terri thought enviously.

"My young assistant was on duty last night when they brought in Paige Thorndyke. Yes, yes, tragic. Have you had an opportunity for any preliminary findings?" He listened. "Really?" he said after one point, his eyebrows rising.

"That's amazing. Negligible, you say? I know, I know." He listened some more.

"It sounds like someone kept in solitary confinement for months." He listened and then looked at Terri while he asked the next question. "Any chemical substances, antibiotics, barbiturates...

"Okay. Appreciate it. Talk to you soon," he added and returned the receiver to its cradle slowly. Then he lifted his eyes toward Terri again.

"Normal plasma ascorbic acid level, as you know, is about 1.5 mg. per 100 cc. He couldn't get any reading... nothing."

"Low levels may sometimes be found in nonscorbutic patients," Terri said softly. "But nothing?"

"Right, and she had no reading in the white cell-platelet layer. She had epistaxis, conjunctival, retinal, cerebral, gastrointestinal, and genitourinary bleeding... all of it," he emphasized. "There's no doubt; this was a severe case of scurvy. It's actually one for the record books."

"What a freaky death for a young, affluent woman in the twenty-first century," Terri said, more to herself than to Hyman.

"She had sexual intercourse right before she was brought in," he added. Terri raised her eyebrows just as Hyman's intercom buzzed.

"Yes, Elaine?"

"Mr. and Mrs. Thorndyke are here to see Dr. Barnard," the receptionist said, her voice cracking with emotion. Elaine Wolf had been with Dr. Templeman nearly as long as he had been practicing. Some older patients considered her evaluation of their condition as good as a preliminary examination. She was a fountain of information when it came to knowledge about families in the community. She asked questions with the forcefulness of a homicide detective and knew if someone came in with bad bronchitis, there were good chances this or that close relative wouldn't be far behind.

"Show them in," Hyman said. He sat back.

"What am I going to tell them?" Terri asked, not disguising the panic in her voice.

"All you know. What else?"

There was a knock at the office door, and Terri rose reluctantly to greet the Thorndykes.

Bradley Thorndyke was still in his pilot's uniform. He was a tall, handsome man in his early fifties with light brown hair and a light complexion that usually gave him a youthful appearance. Now, the weight of mourning and the personal tragedy had added years quickly. His eyes were dark; his skin pale, his shoulders slumped.

Geena Thorndyke was nearly her husband's height. She was an attractive, longlegged, slim woman with ebony hair and dark brown eyes. She clung to her husband for veritable support, her eyes bloodshot, her lips trembling.

"Bradley... Geena," Hyman Templeman said, rising. He went to them quickly and shook Bradley's hand and then put his arm around Geena Thorndyke's shoulders and guided her to the brown leather settee. "I'm so sorry," he said.

"Can you believe this?" Bradley asked. "It makes no sense to us and we couldn't sit at home and wait for something sensible, so we decided to come see the doctor who examined her," he said looking at Terri.

"We were just discussing it," Hyman said stepping back. "Needless to say, it's one of the most unusual things I've seen or heard since I began practicing medicine."

Bradley Thorndyke's gaze swung quickly to Terri again. She felt his sorrow, but she also felt his anger. There was accusation in those eyes. She quickly realized that in their need to understand what had happened to their daughter, the Thorndyke's were searching for a scapegoat, someone to blame so it would make some sense.

"You were on duty when they brought her into the emergency room, right?" he said in an accusing tone.

"Yes. I was with a patient and I heard the STAT and rushed right down. I had just gotten my stethoscope on her chest when she expired," Terri explained. Geena Thorndyke groaned and began to sob.

"They're telling us it looks like she died of acute scurvy," Bradley said, his disdain and disbelief quite evident in his voice.

"Yes, Mr. Thorndyke. It's just about certain that will be the diagnosis."

"That's just ridiculous. She was found unconscious on the floor of a cheap, onenight motel room. She must have been drugged," Bradley insisted. "Someone picked her up and slipped her one of those Ecstasy things or something, an overdose, right?"

"The autopsy doesn't show that, Bradley," Hyman said softly. "There was some alcohol in her blood stream, but no chemical substances."

"Well let them do another autopsy, for Christ sakes! My daughter had to have been murdered. Murdered!"

Hyman Templeman shifted his gaze quickly to Terri and then nodded sympathetically at Bradley Thorndyke.

"I can understand why you would feel this way, Bradley. We're stumped."

"Someone had to have at least hit her or..." He turned to Terri, his hands out,

"Or done something violent to her."

"Every hemorrhage on her body appears to have been caused by fragile capillaries, a classic symptom of scurvy. The autopsy reveals large muscle hemorrhages and petechial and purpuric skin manifestations," Hyman explained, when Terri hesitated.

Bradley shook his head.

"It's not the sort of thing that happens overnight," Terri added. "Not this severe, this quickly. Did either of you notice her becoming weak, irritable? Did she become black and blue at the slightest touch? And her gums... rapidly developing gingival hemorrhages give the appearance of bags of blood," Terri continued. Wide-eyed, both Bradley and Geena looked at her. It was as if she were from another planet.

Geena finally shook her head.

"No, nothing like that," she muttered.

"She wasn't being treated for peptic ulcers, was she?" Hyman asked.

"Ulcers? No," Bradley said. "Besides, you would know. You were her doctor, Hyman."

Doctor Templeman nodded.

"It's been a while since I've seen her," he remarked softly.

"That's because she was as healthy as a horse. You know she was into all that aerobics and exercise. Christ, she ate like someone in training. She was always complaining about our fatty diets, the chemicals in our food. We never ate the right cereals and she would go into tirades over the cholesterol we consumed, right, Geena?"

"What? Oh, yes, yes," she said smiling and wiping her cheeks. "She made me promise to buy this butter substitute because Bradley eats so badly when he's traveling." Her voice trailed off. She caught herself as if she realized she was adding the most inane details to the discussion.

"When did you see your daughter last, Mrs. Thorndyke?" Terri asked softly.

"Two days ago... we had lunch." She started to bury her face in her hands again.

"So what were Paige's dietary habits?" Terri pursued. "I mean, was she following any fads? I know that some people get caught up in these meditation cults and make radical changes in their food habits."

"Meditation cults?" Bradley cried. "This is ridiculous," he said turning back to Hyman. "Scurvy? That comes from a lack of vitamin C, right? A sailor's disease before they knew about vitamins, right?" he insisted. "It has to be a stupid mistake."

"The lab findings are pretty accurate, Bradley. What we were also wondering was had Paige gone on any sort of fad diet to lose weight," Hyman said.

"Absolutely not. I told you. She was into exercise. She didn't have to diet to lose weight. She was in great condition. I know I couldn't keep up with her on the jogging track," Bradley replied. Then he looked down at his wife. "Unless there's something I don't know about," he added. Geena shook her head.

"She wasn't dieting," she said.

"You say you had lunch with her two days ago, Geena?" Hyman asked softly. Geena Thorndyke looked up.

"Yes, but nothing made me sick," she added quickly.

"No, that's not what we're looking for. Do you recall what you ate?"

"We had a salad... chicken salad."

"Paige was in the habit of taking a daily vitamin anyway," Bradley said sharply.

"I know that for a fact because she was always criticizing me for not."

"Uh huh. What did you drink with your salad, Geena?"

"We had... cranberry juice," she said and shook her head so vigorously, Terri thought she was going into a convulsion.

"Well, that's a source of vitamin C," Henry muttered. "And if she was in the habit of taking vitamins daily, she would get the minimum requirements of vitamin C and none of these symptoms would have been precipitated."

"So she couldn't die of scurvy. Right?" Bradley Thorndyke cried with frustration. He turned from Hyman to Terri. They simply stared at each other.

"I'm sorry but we can't explain this, Bradley," Hyman said. "The autopsy report doesn't show a reading of ascorbic acid at all." He sighed. "Dr. Barnard can describe her symptoms when she was first brought into the emergency room. She never had an opportunity to begin any therapy. You will see a copy of the autopsy report, of course, and you will see that all the findings point to scurvy."

"But what was she doing in that cheap motel?" Geena Thorndyke asked, staring down at the floor. She was really asking herself.

No one spoke; only Geena's sobbing broke the heavy silence. She realized it and stopped crying to look up at Terri. Bradley Thorndyke turned to her too, as if he expected she had the answer to Geena's question as well as all the others. Terri felt like she was shrinking under their demanding gazes, and for the first time in her long journey to become a physician, she wanted to run away from the profession.

Nearly eight hours later, Terri emerged from the first examination room where she had seen her final patient for the day and handed Elaine the patients file. She had had little time during the remainder of the workday to dwell on Paige Thorndyke. Before visiting hours had ended, she had seen twenty-five patients. The rapid change in weather characteristic of the Catskill mountain climate engendered the usual minor epidemic of coughs and colds. Many residents stubbornly clung to the remnants of summer, dressing lightly for the daytime and forgetting that the temperatures plummeted in the late afternoon and evening as the sun settled below the peaks and treetops. Shadows grew longer, deeper, darker.

But Terri loved the Catskill fall mornings. They had that wonderfully invigorating crispness to them. Immediately after stepping out, she enjoyed inhaling deeply and feeling the rush of air fill her lungs and wash away the cobwebs woven during another restless night. Her spiders were hatched out of every diagnosis and prognosis. She had an understandable anxiety, a fear of missing something significant, making the wrong diagnosis and therefore causing the unnecessary death of a patient.

"A good doctor is never completely free of that anxiety," Hyman told her when she confessed it to him during one of their frequent tete-a-tetes. "The trick is to recognize the gray areas and be modest enough to ask for a second opinion. Unfortunately, there are some pretty arrogant bastards in our profession. Even when they make a mistake, they refuse to recognize it's their mistake. They blame it on the symptoms being too ambiguous or something. Many even blame the patients, claiming they didn't tell them everything. They see and hear what they want. I suppose there's nothing as dangerous as an arrogant doctor.

"But mind you," he added quickly, fully cognizant of her relationship with Curt,

"I'm not happy with all this malpractice crap. All you've done, in most cases," he interjected, lowering his bifocals, "is substituted one type of parasite for another. In the end the patients will suffer."

Of course, Curt had another view. "If it weren't for the malpractice suits," he claimed, "many unscrupulous and incompetent doctors would have free rein and woe-be-gone the unsuspecting clod who wandered into their waiting rooms." Curt had already successfully represented clients in two malpractice suits. One was a clear case of negligence that Terri couldn't deny. A doctor had rushed a patient through a routine D and C in order to make a golfing date and had neglected to check her blood count. She hemorrhaged and died on the table in the hallway.

Nevertheless, she saw that Curt had been smitten, and like a shark with the taste of blood on his lips, he swam eagerly in the waters of the medical world searching for a new opportunity or, as Hyman would say, a new victim. It wasn't hard to foresee that this would be an area of argument between her and Curt. Her fiance was a strong-minded, firm man, proud of his self-assurance and the old-fashioned grit he believed he had inherited from his father and grandfather. Curt was willing to make the necessary compromises when he had to, but he was always like a combatant dragged kicking and screaming to the negotiating table. He relented; he gave in and made sacrifices, but he didn't do so with a full heart. Even when his opponents won a point, they left the office feeling they had lost.

"There's a policeman here to see you," Elaine whispered sharply, taking her out of her reverie. The gray-haired little woman who always reminded Terri of Gracie Allen shifted her eyes to the left.

Terri was so tired she hadn't noticed the tall, blond-haired man in a dark-blue sports jacket, tie, and slacks standing by the window. He had beautiful blue eyes that fixed on her with remarkable intensity. Broad-shouldered, at least six feet two or three, he stood with a firm demeanor that suggested strength and purpose. Her clinical eyes concluded from the rich sheen of his hair and the robust color of his complexion that he was a healthy, vigorous man. He had a small cleft in his chin and a set of teeth that belonged in toothpaste advertisements.

"Oh," she said. "Thank you, Elaine."

She opened the door and stepped into the waiting room.

"Dr. Barnard, I assume," he said smiling. The twinkle in his eyes made him seem years younger than she imagined he was. He extended his hand and when she placed hers in it, he didn't hesitate to give hers a firm shake. No timidity here, she thought quickly.

"Yes."

"I'm here to talk to you about Paige Thorndyke."

He displayed his badge and card identifying him as a New York State Bureau of Criminal Investigations agent.

"Clark Kent?" she asked, smiling and reading.

"I know, I know," he said putting his identification away quickly. "You can imagine the kind of kidding I have been enduring my entire life. Every time my friends and I approached a telephone booth, they pushed me into it. What can I say, I had parents with a sense of humor."

Terri laughed.

"Let's sit down," she said indicating the waiting room sofa on her right.

"Thank you."

"Why is there an investigation like this? Was something criminal discovered in relation to her death?" she quickly asked, actually hopefully asked.

"It's routine basically. I won't be long. Just tying up loose ends on the Thorndyke woman's death for the district attorney. You were the doctor on duty when they brought her in, right?" he asked sitting back, his long arm along the rear of the sofa.

"Yes, but there wasn't much for me to do. She died within moments of arrival."

"I understand. Did she say anything, anything at all that would lead you to believe someone had done something harmful to her? Perhaps she gave you a name, a description."

"No. I don't believe she had even the strength to speak. She was too far gone." He nodded.

"The traumas you observed are characteristic of those caused by a vitamin deficiency?" he asked.

"As far as I know, yes, but Dr. Templeman and I both think this is going to take a far more expert opinion than ours. It's too bizarre."

"There was nothing that looked like a blow to the face or head?"

"I didn't see anything like that. I examined her face because she was missing some teeth, but except for the hemorrhaging in the gums, there wasn't anything, no contusions about the lips, no bruise on the jaw or cheeks. The autopsy has apparently revealed nothing of the kind either, but you would probably know that."

"Uh huh."

"So? Do you have reason for some suspicion of foul play?" she inquired again.

"She did check into that motel with someone, right?"

"Well, yes, but he was gone by the time she was discovered."

"But can't you track him down? He signed in, paid for the room..."

"He signed a fictitious name and address and he paid in cash, no credit card." Terri sighed deeply, the frustration coming over her like a chill.

"Didn't anyone see him with her earlier? Do we know how she met him at least?"

"Well, she was at this dance club, the Underground, in Monticello earlier that evening. As I understand it, she went there to meet a friend, but her friend never showed. I questioned some of the people who were at the club and they remember her leaving with the man with whom she had been dancing. The bartender said they met at the bar, and from what he had overheard, met for the first time. No one knows anything about the guy. I've got a description," he said, looking at his small notepad. "But not that concise. Some said he had light hair, some thought dark brown. The bartender claims he was in shadows most of the time.

"I was hoping she had said something to you. No matter how insignificant it might seem, it could be important," he emphasized.

"No, as I said, she was too far gone to speak. She didn't know where she was anymore."

Terri looked up at him.

"How was she discovered? In the state she was in when I saw her, I can't imagine her even calling out for help."

"The manager was walking by her room and noticed the door was wide open. When he looked in, she was sprawled on the floor. What about the nurse at the ER or the paramedics... did any of them hear her say anything?"

"Not that I know," she replied and wondered why he didn't just go directly to them.

He anticipated the question.

"I'm just getting into this. I haven't even had an opportunity to speak with her parents yet."

She nodded, imagining how hard that was going to be now.

"It's never easy to understand the death of a child, but something like this especially so. This sort of acute scurvy would have revealed itself through symptoms far earlier. Her parents were here this morning," Terri continued.

"Understandably, they don't believe the cause of death was scurvy. I can't believe it myself, or can Dr. Templeman, but the medical evidence is quite convincing.

"I can't believe that whoever brought her to the motel would not have noticed something," Terri continued. "To begin with her teeth... she would have had bleeding in her mouth, black and blue marks... been tired.... Who would do such a thing, bring a woman that sick to a motel or keep her there once he saw that? Why not get her to a hospital? The therapy was simple and would have saved her life."

"I know. That's what I'd like to know."

"If someone kept a person from getting life-saving medical attention, he would as much as murdered her," Terri concluded.

"Exactly."

"Oh. I see why you would be investigating," she said nodding. "As I understand it, she looked well the day before. At least, that's what her parents say." Terri shook her head. "Everything I know about the disease would make that impossible. The whole thing seems impossible. I can't think of any medical explanation for a practically instantaneous case of acute scurvy. People don't develop something like that overnight, even if they neglect vitamin C for days."

"Maybe drugs caused it," he suggested.

"Haven't you seen a copy of the autopsy report?" she asked.

"Oh yes, but I just wondered. Maybe they missed something," he said quickly.

"There are many drugs that deplete vitamins, but nothing would work this fast and everything I know would show up in an analysis. I'm not going to pass myself off as any world-renowned expert on the subject, however. I'm just a family physician, you understand."

"Of course," he said smiling, "but I can appreciate your frustration."

"I mean her parents told me that she was an exercise fanatic. What can I say? It's a real medical mystery. You don't have any other situations like this, do you?" she asked.

"I don't know yet. I'll have to contact the FBI. I hope not," he said.

"Oh, I would have thought you would have done that already," she said.

"Not enough time. This is my first case on a new position and I get this," he said smirking.

"Oh?"

"I moved out of New York City because my wife wanted a quieter, safer environment for our children."

"How old are they?"

"We don't have any yet," he replied, "but my wife's pregnant."

"Do you live here?"

"No. We moved to the Albany area, a small community just outside the city. It's actually more rural than I had expected, but we like the stressless life, a world without all this urban turmoil."

"Normally this is a safe place to live," Terri said. "I grew up here."

"Really? And you returned to practice medicine here. I guess you do like it." She smiled.

"My fiance lives here. He has a successful law practice."

"Oh." He looked impressed.

She thought a moment.

"You're absolutely sure no one noticed anything unusual about her at the club?" Terri asked, still struggling with the effort to understand and free herself of this terrible frustration.

"The bartender claims she was dancing up a storm." Terri shook her head.

"That would just seem to be impossible. I wish I could tell you something that would clear it all up, but I'm more confused than anyone right now."

"I understand. Well, Doctor, thank you," Kent said rising. "I'm certain we'll reach some satisfactory conclusion."

"Well," she said, "nothing is for certain in this world, but people don't die like this."

"No," he said, "they don't."

He said it as if he knew just as much about medicine as she did. He nodded, thanked her again, and left.

She turned slowly and saw Elaine Wolf seated behind the counter. Of course, she had been listening in. Only now she looked sorry about her curiosity. Her eyes were filled with terror.

It gave Terri a chill that she knew she wouldn't shake off until she had made herself a cocktail at home.