Contagion

16

Despite having gone to bed much later than usual for the second night in a row, Jack was wide awake at five-thirty Friday morning. He began mulling over the irony of a case of tularemia appearing in the middle of a plague outbreak. It was a curious coincidence, especially since he’d made the diagnosis. It was a feat certainly worth the ten dollars and twenty-five cents that he stood to win from Calvin and Laurie.

With his mind churning, Jack recognized the futility of trying to go back to sleep. Consequently he got up, ate breakfast, and was on his bike before six. With less traffic than usual, he got to work in record time.

The first thing Jack did was to visit the ID room to look for Laurie and Vinnie. Both had yet to arrive. Passing back through communications, he knocked on Janice’s door. She appeared even more beleaguered than usual.

“What a night,” she said.

“Busy?” Jack asked.

“That’s an understatement,” she said. “Especially with these added infectious cases. What’s going on over there at the General?”

“How many today?” Jack asked.

“Three,” Janice said. “And not one of them tested positive for plague even though that’s their presumed diagnosis. Also, all three were fulminant cases. The people all died within twelve or so hours after their first symptoms. It’s very scary.”

“All of these recent infectious cases have been fulminant,” Jack commented.

“Do you think these three new ones are tularemia?” Janice asked.

“There’s a good chance,” Jack said. “Especially if they tested negative for plague as you say. You didn’t mention Susanne’s diagnosis to anyone, did you?”

“I had to bite my tongue, but I didn’t,” Janice said. “I’d learned in the past by sore experience that my role is to gather information, not give it out.”

“I had to learn the same lesson,” Jack said. “Are you finished with these three folders?”

“They’re all yours,” Janice said.

Jack carried the folders back to the ID room. Since Vinnie had not arrived Jack made the coffee in the communal pot. Mug in hand, he sat down and began going through the material.

Almost immediately he stumbled onto something curious. The first case was a forty-two-year-old woman by the name of Maria Lopez. What was surprising was that she worked in central supply of the Manhattan General Hospital! Not only that, but she had worked on the same shift as Katherine Mueller!

Jack closed his eyes and tried to think of how two people from central supply could possibly have come down with two different fatal infectious diseases. As far as he was concerned, it could not be a coincidence. He was convinced their illnesses had to be work-related. The question was how?

In his mind’s eye, Jack revisited central supply. He could picture the shelving and the aisles, even the outfits the employees wore. But nothing came to mind as a way for the employees to come in contact with contagious bacteria. Central supply had nothing to do with the disposal of hospital waste or even soiled linen, and as the supervisor had mentioned, workers there had little or no contact with patients.

Jack read the rest of Janice’s investigative report. As she’d done with the cases since Nodelman, she included information about pets, travel, and visitors. For Maria Lopez, none of the three seemed a factor.

Jack opened the second folder. The patient’s name was Joy Hester. In this case Jack felt there was little mystery. She’d been an OB-GYN nurse and had had significant exposure to Susanne Hard just prior to and after the onset of Susanne’s symptoms. The only thing that bothered Jack was recalling that he’d read that person-to-person transmission of tularemia rarely occurred.

The third case was Donald Lagenthorpe, a thirty-eight-year-old petroleum engineer who’d been admitted to the hospital the previous morning. He’d come in through the ER with a refractory bout of asthma. He’d been treated with IV steroids and bronchodilators as well as humidified air and bed rest. According to Janice’s notes, he’d shown steady improvement and had even been campaigning to be released, when he’d had the sudden onset of a severe frontal headache.

The headache had started in the late afternoon and was followed by shaking chills and fever. There was also an increase in cough and exacerbation of his asthmatic symptoms despite the continued treatment. At that point he was diagnosed to have pneumonia, which was confirmed by X ray. Curiously enough, however, a gram stain of his sputum was negative for bacteria.

Myalgia also had become prominent. Sudden abdominal pain and deep tenderness had suggested a possible appendicitis. At seven-thirty in the evening Lagenthorpe had undergone an appendectomy, but the appendix proved to be normal. After the surgery his situation became progressively grave with apparent multisystem failure. His blood pressure dropped and became unresponsive to treatment. Urine output became negligible.

Reading on in Janice’s report, Jack learned that the patient had visited isolated oil rigs in Texas the previous week and had literally been tramping around in desert conditions. Jack also learned that Mr. Lagenthorpe’s girlfriend had recently obtained a pet Burmese cat. But he’d not been exposed to any visitors from exotic places.

“Wow! You’re here early!” Laurie Montgomery exclaimed.

Jack was shocked out of his concentration in time to see Laurie sweep into the ID room and drape her coat over the desk she used for her early-morning duties. It was the last day of her current rotation as supervisor in charge of determining which of the previous night’s cases should be autopsied and who would do them. It was a thankless task that none of the board-certified doctors enjoyed.

“I’ve got some bad news for you,” Jack said.

Laurie paused on her way into communications; a shadow passed over her usually bright, honey-complected face.

Jack laughed. “Hey, relax,” he said. “It’s not that bad. It’s just that you owe me a quarter.”

“Are you serious?” she asked. “The Hard case was tularemia?”

“The lab reported a positive fluorescein antibody last night,” Jack said. “I think it’s a firm diagnosis.”

“It’s a good thing I didn’t bet any more than a quarter,” Laurie said. “You are amassing some impressive statistics in the infectious arena. What’s your secret?”

“Beginner’s luck,” Jack said. “By the way, I have three of last night’s cases here. They’re all infectious and all from the General. I’d like to do at least two of them.”

“I can’t think of any reason why not,” Laurie said. “But let me run over to communications and get the rest.”

The moment Laurie left, Vinnie made his appearance. His face was a pasty color and his heavily lidded eyes were red. From Jack’s perspective he appeared as if he belonged in one of the coolers downstairs.

“You look like death warmed over,” Jack said.

“Hangover,” Vinnie remarked. “I went to a buddy’s bachelor party. We all got whacked.”

Vinnie tossed his newspaper on a desk and went over to the cupboard where the coffee was stored.

“In case you haven’t noticed,” Jack said, “the coffee is already made.”

Vinnie had to stare at the coffee machine with its full pot for several beats until his tired mind comprehended that his current efforts were superfluous.

“How about starting on this instead?” Jack said. He pushed the Maria Lopez folder over to Vinnie. “Might as well get set up. Remember, the early bird…”

“Hold the clichés,” Vinnie said. He took the folder and let it fall open in his hands. “Frankly, I’m not in the mood for any of your sappy sayings. What bugs me is that you can’t come in here when everybody else does.”

“Laurie’s here,” Jack reminded him.

“Yeah, but this is her week for scheduling. You don’t have any excuse.” He briefly read portions of the folder. “Wonderful! Another infectious case! My favorite! I should have stayed in bed.”

“I’ll be down in a few minutes,” Jack said.

Vinnie irritably snapped up his newspaper and headed downstairs.

Laurie reappeared with an armful of folders and dumped them on her desk. “My, my, but we do have a lot of work to do today,” she said.

“I’ve already sent Vinnie down to get prepared for one of these infectious cases,” Jack said. “I hope I’m not overstepping my authority. I know you haven’t looked at them yet, but all of them are suspected plague but tested negative. At a minimum I think we have to make a diagnosis.”

“No question,” Laurie said. “But I should still go downstairs and do my external. Come on, I’ll do it right away, and you can get started.” She grabbed the master list of all the previous night’s deaths.

“What’s the story on this first case you want to do?” Laurie asked as they walked.

Jack gave her a quick synopsis of what he knew about Maria Lopez. He emphasized the coincidence of her being employed in central supply at the General. He reminded her that the plague victim from the day before had also worked in that department. They boarded the elevator.

“That’s kinda strange, isn’t it?” Laurie asked.

“It is to me,” Jack agreed.

“Do you think it’s significant?” Laurie asked. The elevator bumped to a stop, and they got off.

“My intuition tells me it is,” Jack said. “That’s why I’m eager to do the post. For the life of me, I can’t figure out what the association could be.”

As they passed the mortuary office Laurie beckoned to Sal. He caught up to them, and she handed him her master list. “Let’s see the Lopez body first,” she said.

Sal took the list, referred to his own, then stopped at compartment 67, opened the door, and slid out the tray.

Maria Lopez, like her late co-worker, Katherine Mueller, was an overweight female. Her hair was stringy and dyed a peculiar reddish orange. Several IVs were still in place. One was taped to the right side of her neck, the other to her left arm.

“A fairly young woman,” Laurie commented.

Jack nodded. “She was only forty-two.”

Laurie held Maria Lopez’s full-body X ray up to the ceiling light. Its only abnormality was patchy infiltration in her lungs.

“Go to it,” Laurie said.

Jack turned on his heels and headed toward the room where his moon-suit ventilator was charging.

“Of the other two cases you had upstairs, which one would you want to do if you only do one?” Laurie called after him.

“Lagenthorpe,” Jack said.

Laurie gave him a thumbs-up.

Despite his hangover, Vinnie had been his usual efficient self in setting up the autopsy on Maria Lopez. By the time Jack read over the material in Maria’s folder for the second time and had climbed into his moon suit, all was ready.

With no distractions from anyone in the pit besides himself and Vinnie, Jack was able to concentrate. He spent an inordinate amount of time on the external exam. He was determined to find an insect bite if there had been one. He was not successful. As with Mueller, there were a few questionable blemishes, which he photographed, but none he felt were bites.

Jack’s concentration was inadvertently aided by Vinnie’s hangover. Preferring to nurse his headache, Vinnie remained silent, sparing Jack his usual quips and running commentary on sports trivia. Jack reveled in the thought-provoking silence.

Jack handled the internal exam the same way he’d handled those of the previous infectious cases. He was extraordinarily careful to avoid unnecessary movement of the organs to keep bacterial aerosolization to a minimum.

As the autopsy progressed, Jack’s overall impression was that Lopez’s case mirrored that of Susanne Hard, not Katherine Mueller. Hence, his preliminary diagnosis remained tularemia, not plague. This only highlighted his confusion of how two women from central supply had managed to catch these illnesses while other, more exposed hospital workers had avoided them.

When he finished with the internal exam and had taken the samples he wanted, he put aside a special sample of lung to take up to Agnes Finn. Once he had similar samples from Joy Hester and Donald Lagenthorpe, he planned to have them all sent immediately to the reference lab to be tested for tularemia.

By the time Jack and Vinnie had commenced stitching up Maria Lopez, they began to hear voices in the washroom and out in the hall.

“Here come the normal, civilized people,” Vinnie commented.

Jack didn’t respond.

Presently the door to the washroom opened. Two figures entered in their moon suits and ambled over to Jack’s table. It was Laurie and Chet.

“Are you guys finished already?” Chet said.

“It’s not my doing,” Vinnie said. “The mad biker has to start before the sun is up.”

“What do you think?” Laurie asked. “Plague or tularemia?”

“My guess is tularemia,” Jack said.

“That will be four cases if these other two are tularemia as well,” Laurie said.

“I know,” Jack said. “It’s weird. Person-to-person spread is supposed to be rare. It doesn’t make a lot of sense, but that seems par for the course with these recent cases.”

“How is tularemia spread?” Chet asked. “I’ve never seen a case.”

“It’s spread by ticks or direct contact with an infected animal, like a rabbit,” Jack said.

“I’ve got you scheduled for Lagenthorpe next,” Laurie told Jack. “I’m going to do Hester myself.”

“I’m happy to do Hester as well,” Jack said.

“No need,” Laurie said. “There aren’t that many autopsies today. A lot of last night’s deaths didn’t need to be posted. I can’t let you have all the fun.”

Bodies began arriving. They were being pushed into the autopsy room by other mortuary techs and lifted onto their designated tables. Laurie and Chet moved off to do their own cases.

Jack and Vinnie returned to their suturing. When they were finished, Jack helped Vinnie move the body onto a gurney. Then Jack asked how quickly Vinnie could have Lagenthorpe ready to go.

“What a slave driver,” Vinnie complained. “Aren’t we going to have coffee like everybody else?”

“I’d rather get it over with,” Jack said. “Then you can have coffee for the rest of the day.”

“Bull,” Vinnie said. “I’ll be reassigned back in here helping someone else.”

Still complaining, Vinnie pushed Maria Lopez out of the autopsy room. Jack wandered over to Laurie’s table. Laurie was engrossed in the external exam but straightened up when she caught sight of Jack.

“This poor woman was thirty-six,” Laurie said wistfully. “What a waste.”

“What have you found? Any insect bites or cat scratches?”

“Nothing except a shaving nick on her lower leg,” Laurie said. “But it’s not inflamed, so I’m convinced it’s incidental. There is something interesting. She has definite eye infections.”

Laurie carefully lifted the woman’s eyelids. Both eyes were deeply inflamed, although the corneas were clear.

“I can also feel enlarged preauricular lymph nodes,” Laurie said. She pointed to visible lumps in front of the patient’s ears.

“Interesting,” Jack commented. “That’s consistent with tularemia, but I didn’t see it on the other cases. Give a yell if you come across anything else unusual.”

Jack stepped over to Chet’s table. He was happily engrossed in a multiple gunshot wound case. At the moment he was busy photographing the entrance and exit wounds. When he saw Jack he handed the camera to Sal, who was helping him, and pulled Jack aside.

“How was your time last night?” Chet asked.

“This is hardly the best time to discuss it,” Jack said. Conversation in the moon suits was difficult at best.

“Oh, come on,” Chet said. “I had a blast with Colleen. After the China Club we went back to her pad on East Sixty-sixth.”

“I’m happy for you,” Jack said.

“What did you guys end up doing?” Chet asked.

“You wouldn’t believe me if I told you,” Jack said.

“Try me,” Chet challenged. He leaned closer to Jack.

“We went over to her office, and then we came over here to ours,” Jack said.

“You’re right,” Chet said. “I don’t believe you.”

“The truth is often difficult to accept,” Jack said.

Jack used Vinnie’s arrival with Lagenthorpe’s corpse as an excuse to return to his table. Jack pitched in to help set up the case because it was preferable to further grilling by Chet. Besides, it made it possible to start the case that much sooner.

On the external exam the most obvious abnormality was the freshly sutured, two-inch-long appendectomy incision. But Jack quickly discovered more pathology. When he examined the corpse’s hands he found subtle evidence of early gangrene on the tips of the fingers. He found some even fainter evidence of the same process on the man’s earlobes.

“Reminds me of Nodelman,” Vinnie said. “It’s just less, and he doesn’t have any on his pecker. Do you think it’s plague again?”

“I don’t know,” Jack said. “Nodelman didn’t have an appendectomy.”

Jack spent twenty minutes diligently searching the rest of the body for any signs of insect or animal bites. Since Lagenthorpe was a moderately dark-skinned African-American, this was more difficult than it had been with the considerably lighter-skinned Lopez.

Although Jack’s diligence didn’t reward him with any bite marks, it did make it possible for him to appreciate another subtle abnormality. On Lagenthorpe’s palms and soles there was a faint rash. Jack pointed it out to Vinnie, but Vinnie said he couldn’t see it.

“Tell me what I’m looking for,” Vinnie said.

“Flat, pinkish blotches,” Jack said. “Here’s more on the underside of the wrist.”

Jack held up Lagenthorpe’s right arm.

“I’m sorry,” Vinnie said. “I don’t see it.”

“No matter,” Jack said. He took several photographs even though he doubted the rash would show up. The flash often washed out such subtle findings.

As Jack continued the external exam he found himself progressively mystified. The patient had come in with a presumed diagnosis of pneumonic plague, and externally he resembled a plague victim, as Vinnie had pointed out. Yet there were discrepancies. The record indicated he’d had a negative test for plague, which made Jack suspect tularemia.

But tularemia seemed implausible because the patient’s sputum test had shown no free bacteria. To complicate things further, the patient had had severe enough abdominal symptoms to suggest appendicitis, which he proved not to have. And on top of that he had a rash on his palms and soles.

At that point Jack had no idea what he was dealing with. As far as he was concerned, he doubted the case was either plague or tularemia!

Starting the internal exam, he immediately came across strong presumptive evidence that substantiated his belief. The lymphatics were minimally involved.

Slicing open the lung, Jack also detected a difference even on gross from what he’d expect to see in either plague or tularemia. To Jack’s eye Lagenthorpe’s lung resembled heart failure more than it did infection. There was plenty of fluid but little consolidation.

Turning to the other internal organs, Jack found almost all of them involved in the pathological process. The heart seemed acutely enlarged, as were the liver, the spleen, and the kidneys. Even the intestines were engorged, as if they had stopped functioning.

“Got something interesting?” a husky voice demanded.

Jack had been so absorbed, he hadn’t noticed that Calvin had nudged Vinnie aside.

“I believe I do,” Jack managed.

“Another infectious case?” another gruff voice asked.

Jack’s head swung around to his left. He’d recognized the voice immediately, but he had to confirm his suspicion. He was right. It was the chief!

“It came in as a presumed plague,” Jack said. He was surprised to see Bingham; the chief rarely came into the pit unless it was a highly unusual case or one that had immediate political ramifications.

“Your tone suggests you don’t think it is,” Bingham said. He leaned over the open body and glanced in at the swollen, glistening organs.

“You are very perceptive, sir,” Jack said. He made a specific effort to keep his patented sarcasm from his voice. This was one time he meant the compliment.

“What do you think you have?” Bingham asked. He poked the swollen spleen gingerly with his gloved hand. “This spleen looks huge.”

“I haven’t the faintest idea,” Jack said.

“Dr. Washington informed me this morning that you’d made an impressive diagnosis on a case of tularemia yesterday,” Bingham said.

“A lucky guess,” Jack said.

“Not according to Dr. Washington,” Bingham said. “I’d like to compliment you. Following on the heels of your astute and rapid diagnosis of the case of plague, I’m impressed. I’m also impressed you left it up to me to inform the proper authorities. Keep up the good work. You make me happy I didn’t fire you yesterday.”

“Now that’s a backhanded compliment,” Jack said. He chuckled, and so did Bingham.

“Where’s the Martin case?” Bingham asked Calvin.

Calvin pointed. “Table three, sir,” he said. “Dr. McGovern’s doing it. I’ll be over in a second.”

Jack watched Bingham long enough to see Chet’s double take when he recognized the chief. Jack turned back to Calvin. “My feelings are hurt,” he said jokingly. “For a moment I thought the chief came all the way down here and suited up just to pay me a compliment.”

“Dream on,” Calvin said. “You were an afterthought. He really came down about that gunshot wound Dr. McGovern is doing.”

“Is it a problem case?” Jack asked.

“Potentially,” Calvin said. “The police claim the victim was resisting arrest.”

“That’s not so uncommon,” Jack said.

“The problem is whether the bullets went in the front or the back,” Calvin said. “Also there were five of them. That’s a bit heavy-handed.”

Jack nodded. He understood all too well and was glad he wasn’t doing the case.

“The chief didn’t come down here to compliment you, but he did it just the same,” Calvin said. “He was impressed about the tularemia, and I have to admit I was too. That was a rapid and clever diagnosis. It’s worth ten bucks. But I’ll tell you something: I didn’t appreciate that little ruse you pulled in the chief’s office yesterday about our bet. You might have confused the chief for a moment, but you didn’t fool me.”

“I assumed as much,” Jack said. “That’s why I changed the subject so quickly.”

“I just wanted you to know,” Calvin said. Leaning over Lagenthorpe’s open corpse, he pushed on the spleen just as Bingham had done. “The chief was right,” he said. “This thing is swollen.”

“So’s the heart and just about everything else,” Jack said.

“What’s your guess?” Calvin asked.

“This time I don’t even have a guess,” Jack admitted. “It’s another infectious disease, but I’m only willing to bet it’s not plague or tularemia. I’m really starting to question what they are doing over there at the General.”

“Don’t get carried away,” Calvin said. “New York is a big city and the General is a big hospital. The way people move around today and with all the flights coming into Kennedy day in and day out, we can see any disease here, any time of the year.”

“You’ve got a point,” Jack conceded.

“Well, when you have an idea what it is, let me know,” Calvin said. “I want to win that twenty dollars back.”

After Calvin left, Vinnie moved back into place. Jack took samples from all the organs and Vinnie saw to it that they were placed in preservative and properly labeled. After all the samples had been taken, they both sutured Lagenthorpe’s incision.

Leaving Vinnie to take care of the body, Jack wandered over to Laurie’s table. He had her show him the cut surfaces of the lungs, liver, and spleen. The pathology mirrored that of Lopez and Hard. There were hundreds of incipient abscesses with granuloma formation.

“Looks like another case of tularemia,” Laurie said.

“I can’t argue with you,” Jack said. “But this issue of person-to-person spread being so rare bugs me. I don’t know how to explain it.”

“Unless they all were exposed to the same source,” Laurie said.

“Oh sure!” Jack exclaimed scornfully. “They all happened to go to the same spot in Connecticut and feed the same sick rabbit.”

“I’m just suggesting the possibility,” Laurie complained.

“I’m sorry,” Jack said. “You’re right. I shouldn’t jump on you. It’s just that these infectious disease cases are driving me bananas. I feel like I’m missing something important, and yet I have no idea what it could be.”

“What about Lagenthorpe?” Laurie asked. “Do you think he had tularemia as well?”

“No,” Jack said. “He seems to have had something completely different, and I have no idea what.”

“Maybe you are getting too emotionally involved,” Laurie suggested.

“Could be,” Jack said. He was feeling a bit guilty about wishing the worst for AmeriCare regarding the first case. “I’ll try to calm down. Maybe I should go do more reading on infectious diseases.”

“That’s the spirit,” Laurie said. “Instead of stressing yourself out, you should treat these cases as an opportunity to learn. After all, that’s part of the fun of this job.”

Jack tried vainly to peer through Laurie’s plastic face mask to get an idea of whether she was being serious or just mocking him. Unfortunately with all the reflections from the overhead lights, he couldn’t tell.

Leaving Laurie, Jack stopped briefly at Chet’s table. Chet was not in a good mood.

“Hell,” he said. “It’s going to take me all day to trace these bullet paths the way Bingham suggested. If he wants to be this particular, I wonder why he doesn’t do the case himself.”

“Yell if you need any help,” Jack said. “I’ll be happy to come down and lend a hand.”

“I might do that,” Chet said.

Jack disposed of his protective gear, changed into his street clothes, and made sure his ventilation charger was plugged in. Then he got the autopsy folders for Lopez and Lagenthorpe. From Hester’s folder he looked up her next of kin. A sister was listed whose address was the same as the deceased. Jack surmised they were roommates. He copied down the phone number.

Next Jack sought out Vinnie, whom he found coming out of the walk-in cooler where he’d just deposited Lagenthorpe’s corpse.

“Where are all the samples from our two cases?” Jack asked.

“I got ’em all under control,” Vinnie said.

“I want to take them upstairs myself,” Jack said.

“Are you sure?” Vinnie asked. Running up the samples to the various labs was always an excuse for a coffee break.

“I’m positive,” Jack said.

Once he was armed with all the samples plus the autopsy folders Jack set out for his office. But he made two detours. The first was to the microbiology lab, where he sought out Agnes Finn.

“I was impressed with your diagnosis of tularemia,” Agnes said.

“I’m getting a lot of compliments out of that one,” Jack said.

“Got something for me today?” Agnes asked, eyeing Jack’s armful of samples.

“I do, indeed,” Jack said. He found the appropriate sample from Lopez and put it on the corner of Agnes’s desk. “This is another probable tularemia. Another sample will come up from a case Laurie Montgomery is doing as we speak. I want them both tested for tularemia.”

“The reference lab is very eager to follow up on the Hard case, so that won’t be difficult. I should have results back today. What else?”

“Well, this one is a mystery,” Jack said. He put several samples from Lagenthorpe on Agnes’s desk. “I don’t have any idea what this patient had. All I know is that it’s not plague, and it’s not tularemia.”

Jack went on to describe the Lagenthorpe case, giving Agnes all the positive findings. She was especially interested that no bacteria had been reported on the gram stain of the sputum.

“Have you thought of virus?” Agnes asked.

“As much as my limited infectious disease knowledge would allow,” Jack admitted. “Hantavirus crossed my mind, but there was not a lot of hemorrhage.”

“I’ll start some viral screening with tissue cultures,” Agnes said.

“I plan to do some reading and maybe I’ll have another idea,” Jack said.

“I’ll be here,” Agnes assured him.

Leaving microbiology, Jack went up to the fifth-floor histology lab.

“Wake up, girls, we have a visitor,” one of the histology techs shouted. Laughter echoed around the room.

Jack smiled. He always enjoyed visiting histology. The entire group of women who worked there always seemed to be in the best of moods. Jack was particularly fond of Maureen O’Conner, a busty redhead with a devilish twinkle in her eye. He was pleased when he saw her round the corner of the lab bench, wiping her hands on a towel. The front of her lab coat was stained a rainbow of colors.

“Well now, Dr. Stapleton,” she said in her pleasant brogue. “What can we do for the likes of you?”

“I need a favor,” Jack said.

“A favor, he says,” Maureen repeated. “You hear that, girls? What should we ask in return?”

More laughter erupted. It was common knowledge that Jack and Chet were the only two unmarried male doctors, and the histology women liked to tease them.

Jack unloaded his armful of sample bottles, separating Lagenthorpe’s from Lopez’s.

“I’d like to do frozen sections on Lagenthorpe,” he said. “Just a few slides from each organ. Of course, I want a set of the regular slides as well.”

“What about stains?” Maureen asked.

“Just the usual,” Jack said.

“Are you looking for anything in particular?” Maureen inquired.

“Some sort of microbe,” Jack said. “But that’s all I can tell you.”

“We’ll give you a call,” Maureen said. “I’ll get right on it.”

Back in his office, Jack went through his messages. There was nothing of interest. Clearing a space in front of himself, he set down Lopez’s and Lagenthorpe’s folders intending to dictate the autopsy findings and then call the next of kin. He even intended to call the next of kin of the case Laurie was doing. But instead his eye caught sight of his copy of Harrison’s textbook of medicine.

Pulling out the book, Jack cracked it open to the section on infectious disease and began reading. There was a lot of material: almost five hundred pages. But he was able to scan quickly since much of it was information he’d committed to memory at some point in his professional career.

Jack had gotten to the chapters on specific bacterial infections when Maureen called. She said that the frozen section slides were ready. Jack immediately walked down to the lab to retrieve them. He carried them back to his office and moved his microscope to the center of the desk.

The slides were organized by organ. Jack looked at the sections of the lung first. What impressed him most was the amount of swelling of the lung tissue and the fact that he saw no bacteria.

Looking at the heart sections, he could immediately see why the heart had appeared swollen. There was a massive amount of inflammation, and the spaces between the heart muscle cells were filled with fluid.

Switching to a higher power of magnification, Jack immediately appreciated the primary pathology. The cells lining the blood vessels that coursed through the heart were severely damaged. As a result, many of these blood vessels had become occluded with blood clots, causing multiple tiny heart attacks!

With a shot of adrenaline coursing through his own circulation from the excitement of discovery, Jack quickly switched back to the section of lung. Using the same high power he saw identical pathology in the walls of the tiny blood vessels, a finding he hadn’t noticed on his first examination.

Jack exchanged the lung section with one from the spleen. Adjusting the focus, he saw the same pathology. Obviously it was a significant finding, one that immediately suggested a possible diagnosis.

Jack pushed back from his desk and made a quick trip back to the micro lab and sought out Agnes. He found her at one of the lab’s many incubators.

“Hold up on the tissue cultures on Lagenthorpe,” he said breathlessly. “I got some new information you’re going to love.”

Agnes regarded him curiously through her thick glasses.

“It’s an endothelial disease,” Jack said excitedly. “The patient had an acute infectious disease without bacteria seen or cultured. That should have given it away. He also had the faintest beginnings of a rash that included his palms and soles. Plus he’d been suspected of having appendicitis. Guess why?”

“Muscle tenderness,” Agnes said.

“Exactly,” Jack said. “So what does that make you think of?”

“Rickettsia,” Agnes said.

“Bingo,” Jack said, and he punched the air for emphasis. “Good old Rocky Mountain spotted fever. Now, can you confirm it?”

“It’s as difficult as tularemia,” Agnes said. “We’ll have to send it out again. There is a direct immunofluorescent technique, but we don’t have the reagent. But I know the city reference lab has it, because there’d been an outbreak of Rocky Mountain spotted fever in the Bronx in eighty-seven.”

“Get it over there right away,” Jack said. “Tell them we want a reading as soon as they can get it to us.”

“Will do,” Agnes said.

“You’re a doll,” Jack said.

He started for the door. Before he got there Agnes called out to him: “I appreciate you letting me know about this as soon as you did,” she said. “Rickettsias are extremely dangerous for us lab workers. In an aerosol form it is highly contagious. It’s as bad or worse than tularemia.”

“Needless to say, be careful,” Jack told her.