Vital Signs

7

"Want to flip to see who does the incision?" Ken Mueller said to Greg Hommel, the junior pathology resident who had been assigned to him for a month's rotation doing postmortems.

Ken was particularly pleased with Greg. The kid was eager and smart as a whip. Ken smiled to himself calling Greg a kid; the guy was only five years younger than himself.

"Heads I win, tails you lose," Greg said.

"Flip," Ken said, already engrossed in the chart. The patient was a thirty-three-year-old woman who'd fallen six stories into a rhododendron planter.

"Tails!" Greg called out.

"You lose." He laughed happily.

Greg loved doing posts. Whereas some of the other junior residents hated it, he thought it was a gas; a detective story wrapped up in the mystery of a body.

Ken didn't share Greg's enthusiasm for posts, but he accepted his teaching responsibilities with equanimity, especially with a resident like Greg. Yet looking at the patient's chart, he felt a little irritated. It had been well over twenty-four hours since the patient's death, and Ken liked to do posts as soon as possible. He thought he was able to learn more.

The patient in this case had been brought to the Memorial by ambulance for a brief resuscitation attempt but the woman had been declared DOA. Then the body had sat in cold storage. It was supposed to have been sent to the medical examiner's office, but between a rash of shootings and other trauma, the ME had been swamped. Finally, a request had come through for them to do the post at the Memorial and Ken's chief had gladly agreed.

It was always politically wise to stay on the ME's good side. You I never knew when a return favor would be needed.

With his gloved. left hand providing counter traction Greg was about to make the typical Y-shaped autopsy incision when Ken told him to hold up.

"Have you gone over the chart?" Ken asked.

"Of course," Greg said, almost hurt by the implication.

"So you know about this infertility stuff?" Ken asked while he was still reading.

"The in-vitro attempts and the blocked tubes."

Blocked tubes had rung a bell, and Ken recalled Marissa's visit.

"Yup, and she looks like a pincushion because of it," Greg said.

Ken glanced at the body as Greg pointed to the multiple hormone-injection sites as well as the multiple bruises where blood had been drawn to measure estrogen levels.

"Ouch," Ken said, looking down.

"And here's a fresh one," Greg said, pointing to the crook of the left elbow.

"See the heme staining under the skin? She had blood drawn within hours of her jumping out the window.

Couldn't have been from our ER. She was dead when she arrived."

Slowly, the doctors' eyes met. They were thinking the same thought. The patient certainly wasn't a drug addict.

"Maybe we should extend the toxicology screen," Greg said ominously.

"Just what I was about to suggest," Ken said.

"Remember, we're being paid to be suspicious."

" You're being paid," Greg laughed.

"As a resident, my salary is more like alms."

"Oh, come on!" Ken said.

"When I was at your stage..

"Spare me," Greg said, holding the knife aloft. He laughed.

"I've already heard what medicine was like in medieval times."

"What about the evidence of the trauma from the faUT' Ken asked.

Rapidly, Greg ticked off the external signs of impact. It was apparent that both legs were broken, as was the pelvis. The right wrist was also bent at an abnormal angle. The head, however, was intact.

"All right," Ken said, "cut away."

With a few deft strokes, Greg used the razor-sharp knife to cut through the skin, exposing the omentum-covered intestines.

Then, with large clippers, he cut through the ribs.

"Uh-oh!" Greg said, lifting off the manubrium, or breastbone.

"We got some blood in the chest cavity."

"What does that suggest?" Ken asked.

"I'd say aortic rupture," Greg said.

"Six stories could have generated the two thousand pounds of force necessary."

"My, my," Ken teased, "you must be doing some extracurricular reading."

"Occasionally," Greg admitted.

Carefully, the two men extracted the blood from both lung cavities.

"Maybe I'm wrong about the aortic rupture," Greg said, staring at the graduated cylinder when they were done.

"Only a few hundred cc's."

"I don't think so," Ken said. He withdrew his hand from inside the chest cavity.

"Feel along the aortic arch."

Looking up at the ceiling as he concentrated on feel, Greg palpated along the aorta. His finger slipped inside. It was an aortic rupture, all right.

"You have promise as a pathologist after all," Ken said.

"Thanks, all-seeing, all-knowing Karnak the Magnificent," Greg joked, though he was obviously pleased with the compliment.

He turned his attention to the evisceration of the corpse.

But as he worked, his forensic mind was beginning to set off alarm bells in his head. There was something wrong with this case; something very wrong.

Having gone through an embryo transfer before, Marissa knew what to expect. There wasn't much pain involved, especially in comparison with the myriad procedures she'd been enduring over the year, but it was still an uncomfortable and humiliating exercise. To keep her uterus in a dependent position, she had to lie prone with her knees raised to her chest and with her rear end sticking up in the air. Although she had a sheet draped over her, Marissa felt completely exposed. The only people present were Dr. Wingate, his nurse-technician, Tara MacLiesh, and Mrs. Hargrave. But then the door opened and Linda Moore came in. The fact that people could come in and out was part of the reason Marissa felt so vulnerable.

"It's important for you to be relaxed," Linda said, positioning herself near Marissa's head. She patted Marissa's shoulder.

"I want you to think relaxing thoughts."

Marissa knew the therapist meant well, but telling her to think relaxing thoughts seemed absurd. She hardly saw how it would help. And it was particularly hard to relax knowing Robert was outside waiting. Marissa had been surprised he'd come with her that morning since he'd slept in the guest room again.

"Everything is ready," Dr. Wingate said, keeping Marissa informed, as usual.

"And just like we did last time, the first thing we have to do is assure asepsis."

Marissa felt the sheet drawn back. Now she was literally exposed.

She closed her eyes as Linda continued to drone on about relaxing. But Marissa couldn't relax. So much was riding on this transfer, maybe even her marriage. Robert had accompanied her to the clinic, but neither of them had said a single word through the entire drive from Weston to Cambridge.

"First the sterile speculum," Dr. Wingate said. A few seconds later, she felt the instrument.

"Now I will be rinsing with the culture medium," Wingate continued.

Marissa felt the rush of fluid inside her. Then she felt a hand on her shoulder. Opening her eyes, she saw that Linda Moore's freckled face was inches from her own.

"Are you relaxed?" Linda asked her.

Marissa nodded, but it was a lie.

"We're ready for the embryos now," Dr. Wingate told Tara.

Tara went back into the lab. Then to Marissa, Dr. Wingate said:

"You might feel a tiny bit of cramping with the insertion, but don't worry. It will be just like last time."

Marissa. would have preferred he'd not made the comparison: last time the transfer had not worked. She heard Tara come back into the room. Marissa could picture the Teflon catheter, called a Tomcat.

"This is it," Dr. Wingate continued.

"Remember to relax," Linda said.

"Think of a fine, healthy baby," Mrs. Hargrave said.

Marissa felt a strange deep sensation like a pain, but not strong enough to be called a pain.

"We should be within one centimeter of your uterine fundus," Dr. Wingate said.

"I'm injecting now."

"Breathe deeply," Mrs. Hargrave said.

"Relax," Linda suggested.

Despite her hopes, Marissa didn't feel optimistic.

"Perfect," Dr. Wingate said.

"I'm coming out now."

Marissa held her breath as she experienced an extremely mild cramp' Now don't move until we ascertain that the embryos have all been extruded from the catheter," Dr. Wingate said. He and Tara disappeared into the lab.

"You feel okay?" Mrs. Hargrave asked.

"Fine," said Marissa, as self-conscious as ever, always concerned someone else was about to barrel through the door, "Now that it's over," Linda said, giving Marissa's shoulder another pat, "I'll be going. I think I'll have a word with your husband on my way out."

Good luck, Marissa thought. She didn't think her husband would be approachable that day.

Dr. Wingate returned just as Linda was departing.

"All the embryos were planted," Dr. Wingate said. Marissa felt the speculum being removed. He tapped her gently on the top of her rump.

"Now you can lower yourself to your tummy. But don't roll over. Just like the previous transfer: I want you to remain on your stomach for three hours, then you can roll over on your back for an hour. Then you'll be free to go." He pulled the sheet over Marissa's lower half.

Mrs. Hargrave released the brakes on the gurney and started pushing. Tara held open the door to the hallway. Marissa thanked Dr. Wingate.

"You're very welcome, love," he said, his Australian accent suddenly more pronounced.

"We'll all be keeping our fingers crossed."

As they came abreast of the waiting room, Marissa heard Mrs.

Hargrave call out Robert's name. The conversation with Linda must have been brief, as she was already gone.

Robert fell in beside them as Mrs. Hargrave pushed Manissa across the glassed walkway to the overnight ward.

"I was told everything went smoothly," he said.

"We're very optimistic," Mrs. Hargrave said.

"They were fine eggs and fine embryos."

Marissa didn't say anything. She could tell Robert wasn't happy. Linda had no doubt irritated him, The room that Marissa was placed in for her four-hour wait was pleasant enough. There were yellow curtains over windows that looked out onto the Charles River. The walls were a restful light green color.

Marissa was gingerly transferred from the gurney to the bed.

Following orders, she lay quietly on her abdomen, her head to the side. Robert sat in a vinyl chair facing her.

"You feel okay?" he asked.

"As well as can be expected," Marissa said evasively.

"You'll be all right?" he asked.

Marissa could tell he was impatient to go.

"AN I'm doing is lying here," she told him.

"If you have things to do, please, go do them. I'll be fine."

"You're sure?" Robert stood up.

"I suppose if you are comfortable, there are some things I ought to attend to."

Marissa could tell he was grateful to be excused. Before he left he gave her a quick peck on the cheek.

The way she'd been feeling lately, Marissa was initially more comfortable left alone. But as the hours crawled by, she started to feel lonely, even abandoned She began to look forward to the infrequent visits by one of the Women's Clinic staff who dropped by to check on her every now and then.

When four hours had passed, Mrs. Hargrave came back to help her dress. At first, Marissa was reluctant to stand up, fearing she would spoil the transfer, even though the prescribed time had gone by. Mrs. Hargrave was nothing but encouraging.

Before Marissa left the clinic, Mrs. Hargrave advised her to take it easy for the next few days. She also told her to avoid sex for a little while.

No problem there, Marissa thought forlornly, especially if Robert continued to sleep in the guest room. She couldn't remember the last time the two of them had had sex.

Marissa arranged for a cab to come pick her up. The last thing she wanted to do was call Robert for a ride.

She spent the remainder of the day resting. At seven o'clock she watched the news, keeping an ear out for the sound of Robert's car in the driveway. By eight o'clock she began eyeing the phone. At eight-thirty she broke down and called his office.

Marissa let the phone ring twenty-five times, hoping that he was there by himself and would eventually hear it even if it wasn't ringing in his private office. But no one picked up.

Hanging up the receiver, Marissa stared at the clock, wondering where Robert could be. She tried to tell herself he was probably on his way home. Marissa had promised herself she wouldn't cry. She was afraid it might somehow jeopardize the embryos.

But as she sat alone in the dark waiting for Robert to come home at last, loneliness overcame her. Despite her best intentions, tears began to slide down her cheeks. Even if she was pregnant, at this point she wasn't sure it would be enough to save her marriage.

With deepening despair, she wondered what was going to happen to her life.

Marissa exited from Storrow Drive onto Revere Street at the base of Beacon Hill. As usual, she felt anxious. It had been almost a week since her embryo transfer, and it was difficult for her to think of anything other than the question of whether she was pregnant or not. In just a few days she was scheduled to return to the Women's Clinic to have blood drawn for a test that would indicate whether or not the transfer had been successful.

While waiting for a red light, Marissa looked at the directions she'd written down when she'd spoken to Susan Walker about the Resolve meeting. She was supposed to take a right on Charles, then a left on Mt. Vernon, and another right on Walnut.

The directions advised her to take any parking place she could find on Beacon Hill.

When the light turned green, Marissa turned right. But before she got to Mt. Vernon, she found a parking place. She took it.

Susan Walker's house turned out to be a cute little Georgianstyle town house nestled among several others on picturesque Acorn Street.

The door was opened by an extremely attractive, dark-haired woman in her mid-thirties. She was exquisitely attired in a silk dress that immediately made Marissa feel underdressed. Marissa had worn wool slacks and a sweater.

"I'm Susan Walker," the woman said, extending her hand and shaking Marissa's firmly. Marissa told her her name.

"We're so glad you could come," Susan said as she gestured for Marissa to step into the living room.

In the living room, between twenty and thirty people were milling about, engaging in conversation. The impression was a normal cocktail party with a slight but obvious preponderance of women.

Playing the good hostess, Susan took Marissa around and introduced her to a number of the people present. But then the door chimed again and Susan excused herself.

To Marissa's surprise and relief, she was immediately put at ease. She had thought she would feel out of place, but she didn't at all. All the women seemed warm and friendly.

"And what do you do?" asked Sonya Breverton. Susan had just introduced her to Marissa before leaving to answer the door.

Sonya had told Marissa that she was a stockbroker with Paine Webber.

"I'm a pediatrician," Marissa replied.

"Another doctor!" Sonya remarked.

"It's reassuring that you professionals suffer along with the rest of us. There's another doctor here, an ophthalmologist. Wendy Wilson."

"Wendy Wilson!" Marissa exclaimed, her eyes immediately sweeping the room. She felt a surge of excitement. Could it be the Wendy Wilson she'd gone to Columbia Medical School with?

Her eyes stopped on a woman across the room who was not much taller than herself, with short, sandy-blonde hair.

Marissa excused herself and began to weave her way through the people to her old friend. As she got closer, the impish, pixie like features were immediately unmistakable.

"Wendy!" Marissa shouted, interrupting the woman in mid-sentence.

Wendy turned her eyes to Marissa.

"Marissa!" Wendy cried, giving her a big hug. Wendy quickly introduced Marissa to the woman with whom she'd been speaking, explaining that Marissa was an old medical school chum she'd not seen since graduation.

After exchanging a few pleasantries, the other woman politely excused herself, suspecting they had a lot of catching up to do.

"When did you get to Boston?" Marissa demanded.

"I've been here for over two years. I finished my residency at UCLA, worked for several years at the hospital, then came east with my husband, who took a surgical position at Harvard. I'm at the Mass. Eye and Ear. What about you? When I first got back, I asked about you and was told you'd moved to Atlanta."

"That was just for a two-year stint at the CDC," Marissa explained.

"I've been back for about three years." Quickly she filled Wendy in on her marriage, her practice, where she lived.

"Weston!" Wendy laughed.

"We're neighbors. We live in Wellesley. Hey, you're not here as tonight's lecturer, are you?"

"Afraid not," Marissa said.

"How about you?"

"I wish," Wendy said.

"My husband and I have been trying to have a child for two years now. It's been a disaster."

"Same with me," Marissa admitted.

"I can't believe this. It takes being infertile to meet up with you. And here I was worried that I'd meet someone I knew."

"Is this your first Resolve meetine." Wendy asked.

"I've only been to five or so, but I've never heard your name."

"First one," Marissa admitted.

"I'd always been reluctant to come, but recently a counselor recommended it."

"I've enjoyed it," Wendy said.

"Problem is, I can't get my granite-headed husband here. You know how surgeons are. He hates to admit that somebody might have something to offer in the way of information or expertise."

"What's his name?" Marissa asked.

"Gustave Anderson," Wendy said.

"And he's just what he sounds like: one of those white-blond Swedes from Minnesota."

"I can't Set my husband, Robert, to get near anything that smacks of therapy," Marissa said.

"He's no surgeon, but just as rock-headed."

"Maybe they can talk to each other," Wendy suggested. don't know," Marissa said.

"Robert doesn't like to think he's being manipulated. The therapist tried talking with him after my last transfer, but it only made things worse."

"Excuse me, everybody!" Susan Walker called out over the general din.

"If everyone could find a seat, we'll get going."

Marissa and Wendy sat down on a nearby couch. Marissa was still full of questions for her old friend and had to force herself to be patient. She and Wendy had been quite close during medical school. The fact that they had lost touch was purely a function of geography and their busy careers. After the long forced isolation of infertility, Marissa was overjoyed to find such a former friend in whom she could confide.

But Marissa's patience paid off, and she soon found herself mesmerized by the meeting. A number of the women stood up and addressed the group, telling their own stories.

It was an emotional experience for Marissa as she heard story after story with which she could identify. When one woman confessed to screaming at a shopper in a grocery store who she thought was neglecting her children, Marissa nodded, remembering the teenage mother with the dirty child.

Even one of the husbands got up to talk, making Marissa particularly sorry that she'd been unable to get Robert to come.

He talked about the stress from the male point of view, giving Marissa, a slightly better appreciation of what Robert had been trying to tell her about his response to "performing."

One woman lawyer stood up and spoke of the need for couples going through unsuccessful IVF to grieve for their lost potential children. After eloquently outlining such couples' predicaments, she added quietly, "If there were formal supports for the inferm tiles' grief, maybe my friend and colleague Rebecca Ziegler would be with us tonight."

For a few moments, after the lawyer sat down, the room maintained a respectful silence. Clearly many had been touched by mention of the dead woman. When the next speaker got up, Marissa turned to Wendy.

"Was Rebecca Ziegler a frequent attendee of these meetings?" she asked.

"Yes, poor thing," Wendy said.

"I even spoke with her at the last meeting. It was a shock to hear she'd killed herself."

"Had she been very depressed?" Marissa asked.

Wendy shook her head.

"I never saw signs of it."

"I saw her the day she died," Marissa said.

"In fact, she hit my husband."

Wendy looked at Marissa in surprise.

"It was at the Women's Clinic. She was out of control," Marissa explained.

"Robert was trying to restrain her. The curious thing was that she didn't act depressed then either. She was angry, yes, but not depressed. Was she pretty calm in general?"

"Seemed to be every time I saw her," Wendy said.

"Weird," Marissa said.

"Time for a coffee break," Susan Walker announced after the final speaker.

"Then we'll have tonight's guest give her talk. We are honored to have with us Dr. Alice Mortland from Columbia Medical Center in New York. She will be talking to us about the newest aspects of GIFT, or Gamete Intra-Fallopian Transfer."

Marissa looked at Wendy.

"Are you interested in the lecture?" she asked.

"Not in the slightest," Wendy said.

"With both my fallopian tubes stopped up, GIFT can't help."

"Holy Toledo!" Marissa exclaimed.

"I've got the same problem: sealed tubes."

"My word," Wendy said with a short laugh of disbelief.

"What are we, identical twins? Let's pretend we're in medical school and skip the lecture. We could sneak down to hat bar with he Cheers flag and catch up."

"Will we offend the hostess?" Marissa asked.

"Not Susan," Wendy assured her.

"She'll understand."

Ten minutes later, Marissa and Wendy were seated opposite each other in low-slung vinyl chairs. They were at a large mullioned window that looked out on busy Beacon Street with the darkened Boston Garden beyond. In the light of the lamps, the grass was just starting to become green, one of the first signs of spring.

Both women ordered mineral water and laughed at each other.

"No alcohol! Well, hope springs eternal," Wendy said.

"I had my fourth embryo transfer about a week ago," Marissa admitted.

"Another coincidence," Wendy said.

"So did I. Only mine was my second. What program are you involved with?"

"Women's Clinic in Cambridge," Marissa said.

"I don't believe this," Wendy said.

"I'm there as well. Dr.

Wingate?"

"Yup!" Marissa said.

"Dr. Carpenter is my regular GYN man.

I have Dr. Wingate for in-vitro fertilization."

"I go to Megan Carter," Wendy said.

"I've always preferred a woman gynecologist. But I had to go to Wingate since he runs the IVF show."

"It's amazing we haven't run into each other," Marissa said.

"But then again, they are very good about the confidentiality side of things, which is one of the reasons I started using the clinic in the first place."

"My feelings too," Wendy said.

"I could have gone to someone at the General, but I wasn't comfortable with that."

"Was it a shock to you when you discovered your fallopian tubes were sealed?" Marissa asked.

"Completely," Wendy said.

"I'd never expected it. It was ironic, I thought, considering all the birth control precautions I took all through college and med school. Now I can't remember what it was like not to want a child."

"I feel the same way," said Marissa.

"But I was even more surprised to learn the cause was TB salpingitis."

Wendy slammed her mineral water to the table.

"These coincidences are getting spooky," she said.

"I had the same diagnosisgranulornatous reaction consistent with tuberculosis. I even had a positive PPD skin test."

For almost a full minute the two women stared at each other over the table. This was too much of a coincidence to be believed.

With her epidemiologic training, Marissa was instantly suspicious.

The parallels in their cases were extraordinary. And the only time their lives intersected was during medical school.

"Are you thinking what I'm thinking?" Wendy asked.

"Probably," Marissa said.

"I'm wondering about those months we spent on that elective rotation at Bellevue. Remember those TB cases we saw, especially the drug-resistant ones? Remember they were thinking that there was an upswing in TBT' "How could I forget?"

"Luckily my chest X-ray is perfectly clear," Marissa said.

"So's mine," Wendy said.

"I wonder if we are isolated cases or part of a bigger pattern.

TB salpingitis is supposed to be rare, especially in a healthy nation like the United States." She shook her head. It didn't make sense.

"Why don't we go back to the Resolve meeting and ask if there is anybody else with the same diagnosis?" Wendy suggested.

"Are you serious? The chances are so small, they'd be negligible."

"I'm still curious," Wendy said.

"Come on, it's close and we have a captive audience."

As they walked back toward Acorn Street, Marissa broached the subject of her marital situation. It was hard for her to talk about it, but she felt the need to discuss it with someone. She told Wendy that she and Robert were having serious problems.

"He's taken to sleeping in the guest room," Marissa. confided.

"And he refuses to see a therapist. He says he doesn't need someone to tell him why he's unhappy."

"A lot of us infer tiles have marriage problems," Wendy said.

"Especially those of us in in-vitro. It seems to go with the territory.

Of course everybody deals with it differently. My husband, Gustave, has just transferred what little attention he used to give me to his work. He's always at the hospital. I practically never see him."

"Robert's doing that more and more," Marissa said.

"Unless one of these embryos implants, I'm not all that optimistic we'll be able to weather the storm."

"You've come back!" Susan cried when she opened the door for Marissa and Wendy.

"Just in time for dessert."

Wendy told Susan what they wanted to do. Susan took their coats, then preceded them into the living room, where guests were busily conversing in small groups as they ate chocolatt cake.

"Can I have everyone's attention for one last time," Susan called out. She explained that Wendy had some questions for them.

Positioning herself in the middle of the room, Wendy introduced herself in case there was anyone who wasn't aware that she was a doctor. She then asked how many of the women present had blocked fallopian tubes as the cause of their infertility.

Three people raised their hands.

Looking at these three women, Wendy asked: "Have any of you been told that your tubes were sealed by tuberculosis or what looked like TB under the microscope?"

Each made a questioning gesture, raising their eyebrows. They weren't sure.

"Have any of you been advised to take a drug called isoniazid or INHT' Marissa asked.

"It would have been suggested that you take it for months."

Two of the women raised their hands. Both said that they had been sent to their internists after their laparoscopies and that a drug was mentioned that they'd have to take for an extended period of time. In both instances, however, the drug was not given, and they'd been told to come back every three months.

Marissa wrote down their names and phone numbers: Marcia Lyons and Catherine Zolk. Both promised to inquire with their family doctors to find out for certain if the drug had been isoniazid.

Utterly astonished, Marissa took Wendy aside.

"This is unbelievable.

I think we have four cases. But if these two women had TB, then our medical school rotation at Bellevue is off the hook."

"Four cases doesn't make a series," Wendy cautioned.

"But it is mighty suspicious," Marissa. said.

"Four cases of a rare disease in one geographical area. Besides, it sounds as if none of us has any signs of infection elsewhere. I think we are on to something. I'm going to follow up on it," Marissa vowed.

"Let's do it together," Wendy suggested.

"Wonderful," Marissa agreed.

"The first step will be to take advantage of my contacts at the CDC. We can start that tonight.

Where is your car?"

"It's over at the Mass. Eye and Ear Infirmary," Wendy said.

"Mine's closer," Marissa said.

"I'll drive you to yours and you can follow me home. You game?"

"I'm game," Wendy said.

Saying their goodbyes and thanking their hostess, Marissa suddenly had an idea. She asked Susan if she knew the cause of Rebecca Ziegler's infertility.

"I think it was blocked tubes," Susan said after thinking for a moment.

"I can't be sure, but I believe that's what it was."

"Do you happen to have her phone number?" Marissa asked.

"I believe I do," Susan said.

"Would you mind giving it to me?" Marissa asked.

Susan got the number from her study and gave it to Marissa.

"You aren't going to call Rebecca's husband, are you?"

Wendy asked when they got to the street.

"The poor man is probably in shock."

"I will if I have the courage," Marissa said.

"Besides, I was told they'd separated."

"As if that would make much difference," Wendy said.

"If anything, I would think that would make him feel worse, even responsible."

Marissa nodded.

On the drive home, Marissa's excitement rose. Four cases of isolated TB salpingitis took her case out of the realm of anomaly and suggested a possible trend of public health importance.

Marissa pulled directly into the garage, then exited through the garage door to meet Wendy, who'd parked in the driveway. They entered the house through the front door.

"Nice house," Wendy said as she followed Marissa down a corridor into her study.

"Think so?" Marissa said without enthusiasm.

"It had been Robert's house before we were married. To tell you the truth, I've never liked it."

Marissa went straight to her Rolodex for Cyrill Dubchek's home telephone number.

"I'm calling one of the CDC department heads," Marissa explained.

"We were involved for a little while during my last year at the CDC. He's quite an attractive man."

Marissa found the number and propped the file open with a letter opener.

"Didn't work out?" Wendy asked.

Marissa shook her head.

"It was a stormy relationship from the start. The ironic part is that our major disagreement was over children. He'd had several before his wife died. He wasn't interested in any more. Obviously that was before I knew about my fallopian tubes."

Marissa punched the number on her telephone, then waited for the connection to go through.

"It's quite a story," she said.

"We were at loggerheads during my first couple of months at the center. Then there was romance. At the end we'd evolved into being good friends. Life is unpredictable."

Wendy started to say something, but Marissa hushed her with a raised hand, indicating Cyrill had answered.

The first part of the call was friendly chitchat. Finally Marissa got around to the reason for her call.

"Cyrill," she said, "I have a doctor friend sitting with me and I'm going to put you on the speakerphone." Marissa pushed the appropriate button.

"Can you hear me?"

Cyrill's voice filled the room as he responded in the affirmative.

Marissa got to the point.

"Have you heard any talk around the center of TB salpingitis, like a relatively recent upswing in cases?"

"Not that I can recall offhand," Cyrill said.

"My do you ask?"

"I have reason to believe that there are four such cases up here in Boston. All in relatively young women, and all without any apparent nidus of infection elsewhere, particularly nothing in the lungs."

"What do you mean by 'relatively young women'T' Cyrill asked.

"Late twenties, early to mid-thirties," Marissa answered.

"That's a little old for a pediatrician to be treating," Cyril] said.

"How have these cases come to your attention?"

Marissa smiled.

"I should have known I couldn't be cagey with you, Cyrill," she said.

"The fact of the matter is that I'm one of the infected. I've been involved with in-vitro fertilization for almost a year. Tonight I discovered three other women with the same unusual diagnosis."

"I'm sorry to hear about your troubles," Cyrill said.

"But I haven't heard anything about TB; salpingitis in the usual CDC gossip. What I can do is ask over in bacteriology. If there has been anything at all, they'd be sure to have heard. I'll get back to you as soon as I can."

After appropriate goodbyes, Marissa hung up. Following a slight pause, she asked Wendy what she thought of calling Rebecca Ziegler's number.

Wendy looked at her watch.

"I'm not sure I'd have the emotional fortitude," she said.

"Besides, it's after ten."

"I think it's worth the risk," Marissa said with determination.

She got the number out and dialed. The line rang seven times before someone finally picked up. Loud music could be heard in the background. It sounded like a party.

Marissa asked if she had reached the Ziegler residence.

"Just a minute," the voice at the other end said. Marissa and Wendy could hear the man yell to others to "pipe down a sec."

Then he came back on the line.

"Are you Rebecca Ziegler's husband?" Marissa asked.

"I was," the man said.

"Who is this?"

"I'm Dr. Blumenthal," Marissa. said.

"I hope I'm not catching you at a bad time. I got your number from Resolve, the organization for infertile couples. Are you familiar with it?"

"Yeah," the man said.

"What's up?"

"If it wouldn't be too much of a bother," Marissa said, "I'd like to ask a personal question about Rebecca's condition."

"Is this some kind of crank call?" the man asked. There was a sudden burst of laughter in the background.

"No," Marissa said.

"I can assure you it isn't. I just wanted to ask if Rebecca's problem had anything to do with her fallopian tubeS. those are the tubes that transport the eggs to the uterus."

11 kin w what fallopian tubes are," the man said.

"Just a minute," Then to his guests, the man yelled: "Come on, you guys, shut up! I can't hear!" Coming back on the line he apologized for the commotion.

"My friends," he explained.

"They're a bunch of animals."

"About Rebecca?" Marissa questioned, rolling her eyes for Wendy's benefit.

"Yeah," the man said.

"She had blocked tubes."

"Do you happen to know how they became blockedT'Marissa persisted.

"I just know they were blocked. More than that, you'll have to ask her doctor." There was a crash in the background, and the shatter of broken glass.

"Jesus!" the man said.

"Hey, I gotta go."

Then the line went dead.

Marissa pushed the disconnect button.

They stared at each other. Finally Wendy broke the silence.

"So much for the grieving widower."

"At least we don't have to feel guilty about calling," Marissa said.

"And she had blocked tubes. I think it will be worth looking into the cause. If by any chance her tubes were blocked in the same way as ours, it could put a whole new spin on this affair."

Wendy nodded.

"Wait a second!" Marissa cried.

"What's the matter?" Wendy asked.

"We forgot to ask those other two women where they are being treated. I know Rebecca was at the Women's Clinic."

"You have their numbers," Wendy said.

"Give them a call."

Marissa quickly dialed. Both women were available and both gave the same answer: they were being treated at the Women's Clinic.

"This is getting interesting," Wendy said.

"That's an understatement," Marissa said.

"I think we'd better make a visit to the Women's Clinic, the sooner the better. Like tomorrow morning. Are you with me?"

"I wouldn't miss it for the world," Wendy said.

"Hello," a voice called. Both Marissa's and Wendy's eyes were drawn to the doorway. It was Robert, dressed in a V-necked 'sweater, tan chinos, and loafers without socks. His reading glasses were in his hand.

Marissa stood up from her desk chair and introduced Wendy to Robert, explaining that they'd met at the Resolve meeting. She told him that Wendy was involved with in-vitro fertilization with Dr. Wingate too. Robert shook Wendy's hand.

"I was on my way to the kitchen to make some tea," Robert said.

"Can I interest anyone else?"

"I'd love some," Wendy said.

Robert turned and disappeared toward the kitchen.

"Wow," Wendy said.

"And I thought Gustave was handsome."

Marissa nodded.

"I do love him," she admitted.

"We're just going through a particularly rough time." She shrugged.

"At least that's what I tell myself."

By the time they got to the kitchen, Robert already had the kettle on the stove and boxes of different teas on the table along with three mugs.

"So how was the meeting?" Robert asked as he got VUL LAIG sugar and honey.

Marissa described the meeting, emphasizing how pleasant it was and how many husbands were in attendance.

"Was your husband there?" Robert asked Wendy.

"He was in surgery and couldn't make it," Wendy answered evasively. She neglected to say that he probably wouldn't have attended even if he'd been free. But Robert was a good cross examiner

"Has he been to any of the others?" he asked. Just then, the kettle began to whistle. Robert went to get it.

Marissa answered for Wendy.

"He hasn't been able to make any of the meetings."

"I see," Robert said as he poured boiling water into each of the mugs. He had one of those half-smiles that galled Marissa.

"I'm certain you'd feel differently about the meetings if you had an open enough mind to attend one," Marissa said.

"Maybe I should talk with Wendy's husband," Robert said.

"He sounds like a kindred soul." He took the kettle back to the stove.

"Great idea," Wendy agreed.

"All I can say is that the meeting was extremely rewarding for me," Marissa. said.

"Not only did I meet Wendy, we happened to learn that four of us have the same odd diagnosis."

"Are you talking about the TB stuV" Robert asked.

"Exactly," Wendy said.

"I'm one of the four."

"No kid dine Marissa launched into breathless explanation of exactly how unusual the number of cases was.

"It's so unexpected, we have to look into it. Tomorrow we'll go to the Women's Clinic to launch our official investigation."

"What do you mean your 'official investigation'T' Robert asked.

"We want to know how many cases like ours have been seen.

We want to find out if Rebecca Ziegler had the same problem.

We already know she had blocked tubes."

"The Women's Clinic is not going to, give you that kind of information."

"Why not? It could be important," Marissa said.

"For all we know it might have serious public health consequences. We could really be on to something… something along the lines of toxic shock syndrome."

Robert looked at Marissa, then at Wendy. He found their ardor unsettling, especially in view of Marissa's recent outburst at the Chinese restaurant. No doubt Wendy was strung out on the same hormones.

"I think you guys ought to calm down," Robert told them.

"Even if you get to the bottom of this, it's not like it's going to reverse your condition. And I seriously doubt you'll get very far with the clinic. It would be highly unethical, even illegal, for them to disclose information about their patients without the patients' consent."

But Marissa would hear none of it.

"This TB issue has bothered me from the start. I mean to get to the bottom of it. I don't care what it takes. I just talked to Cyrill Dubchek and he can put the authority of the CDC behind it."

Robert just shook his head. He clearly disapproved.

"Well then," he said curtly, "I'll leave you two sleuths to your plotting."

With that, he picked up his mug and walked away.

Wendy broke the uncomfortable silence once his steps were out of earshot.

"He is right," she said.

"We may have a problem getting access to those medical records."

"We have to give it a try Maybe we can muster some authority as doctors. You know, take the professional approach. If that doesn't work, we'll just think of something else. You are with me, aren't you?"

"Absolutely," Wendy said.

"United we stand."

Marissa smiled. She, could hardly wait for morning.