Crisis

19

To Jack's gratification, things continued to go smoothly. He drove from the Park Meadow to the Langley-Peerson Home without incident, as did Harold with the coffin. When Jack had arrived, Latasha was already there waiting. She had arrived only five minutes earlier, so the timing was nearly perfect.

Immediately on his arrival, Harold had had two of his beefy employees slide the Perpetual Repose coffin out of the hearse and onto a dolly. The dolly had been rolled into the embalming room, where it now stood.

"Here's the plan," Harold said. He was standing next to the coffin with a bony hand resting on its gleaming metallic surface. Thanks to the bright blue-white fluorescent light in the embalming room, any lifelike color he had was washed out, and he looked as if he should have been inside one of the Perpetual Reposes himself.

Jack and Latasha were standing a few feet away near the embalming table, which was going to substitute as the autopsy table. Both had pulled on Tyvek protective jumpsuits that Latasha had thoughtfully brought from the medical examiner's office along with gloves, plastic face screens, and a collection of autopsy tools. Also in the room were Bill Barton, a kindly senior gentleman whom Harold had described as his most trusted employee, and Tyrone Vich, a robust African-American man twice Bill Barton's size. Both had kindly volunteered to stay late and would assist Jack and Latasha in any way needed.

"We'll now open the casket," Harold continued. "I will certify that it indeed contains the remains of the late Patience Stanhope. Bill and Tyrone will remove the clothing and put the body on the embalming table for the autopsy. Once you have finished, Bill and Tyrone will take over to redress the body and return it to the coffin so that it can be re-interred in the morning."

"Will you remain on the premises?" Jack asked.

"I don't think that is necessary," Harold said. "But I live nearby, and Bill or Tyrone can call me if there are any questions."

"Sounds like a plan to me," Jack said, enthusiastically rubbing his gloved hands together. "Let's get the show on the road!"

Taking a crank from Bill, Harold inserted its business end into a flush housing at one end of the metal coffin, seated it, and tried to turn it. The effort brought a fleeting bit of color to his face but failed to turn the locking mechanism. Harold gestured toward Tyrone, who changed places with the director. Tyrone's muscles bulged beneath his cotton scrub shirt, and with an abrupt, torturous screech, the lid began to open. A moment later, there was a short hiss.

Jack looked at Harold. "Is that hissing sound good or bad?" Jack asked. He hoped it was not indicative of gaseous decomposition.

"Neither good nor bad," Harold said. "It speaks to the Perpetual Repose's superb seal, which is not surprising, since it's a top-of-the-line, high-engineered product." Harold directed Tyrone to the opposite end of the casket, where he repeated the process with the crank.

"That should be it," Harold said when Tyrone was finished. He put his fingers under the edge of the coffin and had Tyrone do the same at the other end. Then, in a coordinated fashion, they lifted the lid and allowed light to wash in over Patience Stanhope.

The interior of the casket was lined in white satin, and Patience was clothed in a simple white taffeta dress. In keeping with the decor, her exposed face, forearms, and hands were covered with a white, cottony fluff of fungus. Beneath the mold, her skin was marmoreal gray.

"Without a shred of doubt, this is Patience Stanhope," Harold said piously.

"She looks terrific," Jack said, "all decked out and ready for the prom."

Harold cast a disapproving glance in Jack's direction but kept his thin lips pressed together.

"Okay! Bill and Tyrone," Jack said enthusiastically, "slip her out of her party duds, and we'll get to work."

"I will leave you now," Harold said with a hint of reprimand as if talking to a naughty child. "I hope you find this exercise worthwhile."

"What about your fee?" Jack questioned. He suddenly realized he'd not made any arrangement.

"I have your business card, doctor. We will bill you."

"Perfect," Jack said. "Thanks for your help."

"Our pleasure," Harold said, tongue in cheek. His funeral-director sensibilities had been offended by Jack's disrespectful language.

Jack pulled over a stainless-steel table on casters and put out paper and a pen. He had no recording device, and he wanted to write down his findings as he went along. Then he helped Latasha arrange specimen bottles and the instruments. Although Harold had laid out some of the embalming tools, Latasha had brought the more typical pathology knife, scalpels, scissors, and bone clippers along with the bone saw.

"Your thoughtfulness in bringing all this equipment is going to make this a thousand times easier," Jack said as he attached a new scalpel blade to a scalpel handle. "I was planning on making do with whatever they had here, which in hindsight was not a good idea."

"It was no trouble," Latasha said, glancing around the room. "I didn't know what to expect. I've never seen an embalming room. Frankly, I'm impressed."

The facility was about the same size as her autopsy room at the medical examiner's office but had only a single, central, stainless steel table, giving the impression of wide-open space. The floor and walls were light green ceramic. There were no windows. Instead, there were areas of glass block that let in outside light.

Jack's eyes followed Latasha's around the room. "This is palatial," he said. "When I first conceived of doing this autopsy, I imagined myself using someone's kitchen table."

"Yuck!" Latasha responded. She glanced over at Bill and Tyrone, who were busily disrobing the corpse. "You told me the story about Patience Stanhope and your internist friend on Tuesday when you stopped by. Unfortunately, I've forgotten the details. Could you give me a quick synopsis?"

Jack did better than that. He told the whole story, which included his relationship to Craig as well as the threats he'd received and Craig's children had received about the autopsy issue. He even told her about the incident that morning on the Massachusetts Turnpike.

Latasha was shocked, and her expression reflected it. "I suppose I should have told you this sooner," Jack said. "Maybe you wouldn't have agreed so readily to get involved. But my feeling is that if there was to be trouble at this point, it would have happened before Patience Stanhope came out of the ground."

"I agree with that," Latasha said, recovering to a degree. "Now trouble, if it's going to happen, might depend on what we find."

"You have a point," Jack agreed. "Maybe it would be best if you don't help. If anybody is going to be a target in any form or fashion, I want it to be me."

"What?" Latasha questioned with an exaggerated expression. "And let you boys have all the fun? No thanks! That's never been my style. Let's see what we find and then decide how best to proceed."

Jack smiled. He admired and liked this woman. She had smarts, pluck, and drive.

Bill and Tyrone lifted the corpse out of the casket, carried it over to the embalming table, and heaved it up onto the surface. With a bucket of water and a sponge, Bill gently rinsed away the mold. Like an autopsy table, the embalming table had lips around its periphery and a drain at the end to catch any wayward fluid.

Jack moved over to be on Patience's right while Latasha was on her left. Both had donned their protective face and head gear. Tyrone excused himself to do his nightly security check. Bill retreated to the sidelines to be available if needed.

"The body's in fantastic shape," Latasha commented.

"Harold might be a tad stuffy, but he apparently knows his trade."

Both Jack and Latasha did their own silent external exam. When Latasha was finished, she straightened up.

"I don't see anything I wouldn't have expected," she said. "I mean, she went through a resuscitation attempt and an embalming, and there's plenty of evidence of that."

"I agree," Jack said. He'd been looking at some minor lacerations inside her mouth, which were consistent with having been intubated during the resuscitation. "So far, there's no suggestion of strangulation or burking, but smothering without chest compression still has to be kept in mind."

"It would be way low on my list," Latasha said. "The history pretty much rules it out, you know what I'm saying?"

"I'm with you," Jack said. He handed Latasha a scalpel. "How about you do the honors."

Latasha made the typical Y incision from the points of the shoulders to the midline and then down to the pubis. The tissue was dry like an overcooked turkey with a grayish-tan color. There was no putrefaction, so the smell was fusty but not offensive.

Working quickly and in tandem, Jack and Latasha had the internal organs exposed. The intestines had been completely evacuated with the embalming cannula. Jack lifted the firm edge of the liver. Beneath and affixed to its underside was the gallbladder. He palpated it with his fingers.

"We have bile," he said happily. "That will help with the toxicology."

"We've got vitreous as well," Latasha said, palpating the eyes through the closed lids. I think we should also take a sample of that."

"Absolutely," Jack said. "And urine, too, if we can get it from either the bladder or kidneys."

Each took syringes and took the samples. Jack labeled his while Latasha did the same with hers.

"Let's see if there's an obvious right-to-left shunt," Jack said. "I keep thinking the cyanosis issue is going to prove important."

Carefully, Jack eased away the friable lungs to get a look at the great vessels. After a careful palpation, he shook his head. "Everything looks normal."

"The pathology is going to be in the heart," Latasha said with conviction.

"I think you are right," Jack agreed. He called Bill over and asked if there were any stainless pans or bowls they could use for the organs. Bill produced several from a cabinet below the embalming-room sink.

Proceeding as if they were accustomed to working together, Jack and Latasha removed the heart and lungs en bloc. While she held the pan, Jack lifted the specimen out of the chest and placed it inside. She put the pan down on the table beyond Patience's feet.

"Lungs look normal," Jack said. He rubbed his fingers over the lungs' surface.

"They feel normal, too," Latasha said as she gently prodded them in a few locations. "Too bad we don't have a scale."

Jack called Bill over and asked if a scale was available, but it wasn't.

"The weight feels normal to me," Jack said, hefting the block of tissue.

Latasha tried it but shook her head. "I'm not good at judging weights."

"I'm eager to get to the heart, but maybe we should first do the rest. What do you say?"

"Work first, play later: Is that your motto?"

"Something like that," Jack said. "Let's divide the job to speed things up. One of us could do the abdominal organs while the other does the neck dissection. For completeness' sake, I want to make sure the hyoid bone is intact, even though neither of us thinks strangulation was involved."

"If you are giving me a choice, I'll do the neck."

"You're on."

For the next half-hour they worked silently in their respective areas. Jack used the sink to wash out the intestines. It was in the large intestine that he found the first significant pathology. He called Latasha over and pointed. It was a cancer in the ascending colon.

"It's small, but it looks like it penetrated the wall," Latasha said.

"I think it has," Jack agreed. "And some of the abdominal nodes are enlarged. This is dramatic proof that hypochondriacs do get sick."

"Would that have been picked up by a bowel study?"

"Undoubtedly. If she'd had one. It's in Craig's records that she continually refused his recommendation to do it."

"So it would have killed her if she didn't have the heart attack."

"Eventually" Jack said. "How are you doing with the neck?"

"I'm about done. The hyoid is intact."

"Good! Why don't you get the brain out while I finish up with the abdomen? We're making excellent time." Jack glanced up at the wall clock. It was closing in on eight p.m., and his stomach was growling. "Are you going to take me up on the dinner offer?" he called to Latasha, who was on her way back to the table.

"Let's see what time it is when we finish," she called back over he shoulder.

Jack found a number of polyps throughout Patience's large intestine. When he was finished with the gut, he returned it to the abdominal cavity. "I do have to give Harold Langley credit. His job with Patience Stanhope would have made an ancient Egyptian embalmer proud."

"I don't have much experience with embalmed bodies, but the condition of this one is better than I expected," Latasha said as she plugged in the bone saw. It was a vibrating device designed to cut through hard bone but not soft tissue. She gave it a try. It produced a high-pitched whirring noise. She positioned herself at the head of the table and went to work on the cranium, which she had previously exposed by reflecting Patience's scalp down over her face.

Relatively immune to the racket, Jack palpated the liver, looking for metastases from the cancer in the colon. Not finding any, he made a series of slices through the organ, but it was seemingly clear. He knew that he might find some microscopically, but that would have to be at a later date.

Twenty minutes later, after the brain had been cleared of gross abnormality and a number of specimens from various organs were taken, the two pathologists turned their attention to the heart. Jack had cut away the lungs, so it was sitting in the pan by itself.

"It's like saving the best present for last," Jack said while gazing eagerly and intriguingly at the organ and wondering what secrets it was about to reveal. The size was about that of a large orange. The color of the muscle tissue was gray, but the greasy cap of adipose tissue was light tan.

"It's going to be like dessert," Latasha said with equal enthusiasm.

"Standing here looking at this heart reminds me of a case I did about half a year ago. It was a woman who collapsed in Bloomingdale's and whose heart couldn't be paced by an external pacemaker, just like Patience Stanhope."

"What did you find on that case?"

"A marked developmental narrowing of the posterior descending coronary artery. Apparently, a small thrombosis knocked out a good portion of the heart's conduction system in one fell swoop."

"Is that what you expect to find on this case?"

"It's high on my list," Jack said. "But I also think there is going to be some kind of septal defect causing a right-to-left shunt to account for the cyanosis." Then he added parenthetically, "What it's not going to tell us, I'm afraid, is why someone was so intent on us not finding out whatever it is we are about to learn."

"I think we're going to find widespread coronary disease and evidence of a number of previous small, asymptomatic heart attacks so that her conduction system was particularly at risk prior to the final event, but not compromised enough to show up on a standard ECG."

"That's an interesting thought," Jack said. He glanced across the table at Latasha, who continued to stare at the exposed heart. His respect for her kept growing. He just wished she didn't look nineteen. It made him feel over the hill.

"Remember, postmenopausal women have recently been shown to have different symptomatology than equivalent males when it comes to coronary heart disease! The case you just described is evidence of that."

"Stop making me feel ancient and uninformed," Jack complained.

Latasha made a gesture of dismissal with her gloved hand. "Yeah, sure!" she intoned with a chuckle.

"How about we make a little wager since neither one of us is in our home office, where such activity is frowned upon? I say it's going to be congenital and you say degenerative. I'm willing to put up five bucks in support of my idea."

"Whoa, big spender!" Latasha teased. "Five is a lot of cash, but I'll double you to ten."

"You're on," Jack said. After turning the heart over, he picked up a pair of fine forceps and scissors and went to work. Latasha supported the organ as Jack carefully traced and then opened the right coronary artery, concentrating on the posterior descending branch. When he'd traced it as far as the instruments would allow, he straightened up and stretched his back.

"No narrowing," he said with a combination of surprise and disappointment. Although he usually maintained an open mind diagnostically, for fear of being blinded by the positive finding, in this case he'd been quite certain of the pathology he'd encounter. It was the right coronary artery that supplied blood to most of the heart's conduction system, which had been knocked out by Patience Stanhope's heart attack.

"Don't despair yet," Latasha said. "The ten dollars is still in the balance. There's no narrowing, but I don't see any atheromatous deposits, either."

"You're right. It's perfectly clean," Jack agreed. He couldn't quite believe it. The entire vessel was grossly normal.

Jack turned his attention to the left coronary artery and its branches. But after a few minutes of dissection it was apparent the left was the same as the right. It was devoid of plaque and stricture. He was mystified and chagrined. After all he'd been through, it seemed a personal affront that there was no apparent coronary abnormality, either developmental or degenerative.

"The pathology has to be on the inside of the heart," Latasha said. "Maybe we'll see some vegetations on the mitral or aortic valve that could have thrown off a shower of thrombi that then cleared."

Jack nodded, but he was mulling over the probability of sudden cardiac death from a heart attack with no coronary artery disease. He thought it was extremely small, certainly less than ten percent, but obviously possible, as evidenced by the case in front of him. One thing about forensic pathology that he could always count on was seeing and learning something new.

Latasha handed Jack a long-bladed knife, waking him from a mini trance. "Come on! Let's see the interior."

Jack opened each of the heart's four chambers and made serial slices through the muscular walls. He and Latasha inspected the valves, the septa between the right and left sides of the heart, and the cut surfaces of the muscles. They worked silently, checking each structure individually and methodically. When they were finished, their eyes met across the table.

"The bright side is that neither of us is out ten dollars," Jack said, trying to salvage humor from the situation. "The dark side is that Patience Stanhope is keeping her secrets to herself. She was reputed to be less than cooperative in life, and she's staying in character in death."

"After hearing the history, I'm shocked that this heart appears so normal," Latasha said. "I've never seen this. I guess the answers are going to have to wait for the microscope. Maybe there was some kind of capillary disease process that involved only the smallest vessels of the coronary system."

"I've never heard of such a thing."

"Neither have I," Latasha admitted. "But she died of a heart attack that had to have been massive. We have to see pathology other than a small, asymptomatic colon cancer. Wait a second! What's that eponymous syndrome where the coronary arteries go into spasm?" She motioned to Jack as if she were playing charades, wanting him to come up with the name.

"I honestly have no idea. Now, don't spout some trivia that's going to make me feel inadequate."

"Prinzmetal! That's it." Latasha said triumphantly. "Prinzmetal angina."

"Never heard of it," Jack admitted. "Now you're reminding me of my brother-in-law, who's the victim in this disaster. He'd know it for sure. Can the spasm cause massive heart attacks? That's the question."

"It can't be Prinzmetal," Latasha said suddenly with a wave of dismissal. "Even in that syndrome, the spasm is associated with some stenoses of the vessel nearby, meaning there would be visible pathology, which we don't see."

"I'm relieved," Jack said.

"We have to figure this out one way or the other."

"That's my intention, but not seeing any cardiac pathology has me fooled and even embarrassed, considering all the fuss I've caused to do this autopsy."

"I have an idea," Latasha said. "Let's take all the samples back to my office. We can examine the heart under the stereo dissecting microscope and even do some frozen sections of the heart tis-sue to look at capillaries. The rest of the specimens will have to be processed normally."

"Maybe we should just go have some dinner," Jack said, suddenly wanting to wash his hands of the whole affair.

"I'll pick up some pizza on the way back to the office. Come on! We'll make it a party. There's one hell of a mystery here. Let's see if we can't solve it. We can even get a toxicology screen tonight. I happen to know the night supervisor at the lab at the university. He and I were an item a while back. Things didn't work out, but we're still acquaintances."

Jack's ears pricked up. "Run that by me again!" he said with disbelief. "We could get a toxicology screen done tonight?" Back in New York at the OCME, Jack was lucky to get one in a week.

"The answer is yes, but we'll have to wait until after eleven, when Allan Smitham begins his shift."

"Who's Allan Smitham?" Jack asked. The possibility of an immediate toxicology screen opened up another whole dimension of inquiry.

"We met in college. We took a lot of chem and bio classes together. Then I went to med school and he went to grad school. Now we work a few blocks apart."

"What about your beauty rest?"

"I'll worry about that tomorrow night. You have me hooked on this case. We have to save your brother-in-law from the evil lawyers."