The Silent Sleep of the Dying (Eisenmenger-Flemming Forensic Mysteries) (7 page)

Hartmann had taken the knife and was exposing more of the abdomen. He stripped the skin off the right side of the chest in a mirror image of what Lenny had done, careful not to let the blade slip through the skin and form a "button-hole." This was a crime, as it required Denny or Lenny to suture it and thus work harder; should any of the junior pathologists do such a thing, Denny's usual punishment was to insert a hose down the back of their trousers and turn the water on. Hartmann didn't think Denny would do that to a consultant, but he didn't want to test the proposition.

After a few minutes the entirety of the abdominal contents was displayed.

"Fuck me," was Lenny's invitation, not for the first time unfulfilled.

"What is it?" Lambert was clearly not used to being ignored. Hartmann turned to him and found not only had Wharton come forward but also Belinda had moved within touching distance of the police officers.

"She's got cancer."

Lambert's face complemented the disappointed tone with which he said, "Oh."

"Judging from the extent of the disease, I don't think there's any doubt that's what killed her."

Hartmann, at least, was happy; there was nothing that warmed the cockles of his heart more than finding a cause of death. The constabulary, however, were less than delighted. Clearly they considered that they had been wasting their time. They would probably have left without any further acknowledgement of Hartmann had he not called to their departing backs, "Do you want a copy of the report?"

Lambert looked back and said, "No thanks, doctor. That won't be necessary." It was left to Wharton to say, "Thanks for your time."

They walked out, leaving the world to Belinda and to Hartmann. She moved closer, into the police-shaped gap that had been left by Lambert and Wharton. Her mouth was puckered again. "It's a bit odd, isn't it?" she mused, staring at the girl.

Hartmann had been swept along by the relief that it wasn't a suspicious death, that he would get his eighty pounds and that he wouldn't get bollocked by a forensic pathologist. Her tone caused him to look again. "What do you mean?"

She was hesitant. It didn't do to point out to consultants that they might have missed something. "I was wondering if the skin might not be mycosis fungoides," she explained.

Lymphoma affecting the skin. He was forced to admit that it might be.

Then she said, "But the tumour in her abdomen isn't lymphoma, is it?" And while he was considering this, she continued, "In fact, it's odd-looking altogether. I mean, I've never seen a tumour that filled the abdominal cavity like that. Have you?"

"Oh, yes," he pronounced after a short hesitation that betrayed his lie. "Occasionally." He dredged his false memories. "Ovarian can, sometimes."

He glanced at her, hoping to see confidence in his experience rather than mockery of his falsehood, but she was still staring at the opened corpse and this lack of reaction undermined his hopes. "Two tumours?"

Which was odd, he knew, but odd things happen. "Well, perhaps she really does have psoriasis. Just an incidental finding, and the thing that killed her was the ovarian cancer."

Belinda leaned right over and indicated the nearer shoulder of the corpse with her right hand. "But those growths on her skin. They must be tumour-stage mycosis."

He looked at what she indicated — red, ulcerated nodules, angry and lethal. They might, he thought, be the end stage of skin lymphoma, when it stopped being a rash and became a proper lump-forming cancer, but he wasn't sure. He said only, "Mmm."

"Has she got anything in her past medical history? I mean, you can't develop a huge abdominal tumour like that overnight. Surely she was seeing somebody for it, whatever it is."

He hadn't thought to investigate that — after all, it had been given to him as a possible fire death — and he had therefore to confess that he didn't know. At once she was at the nearby computer terminal, typing in the details that she took from the top of the Coroner's PM request form.

"That's very peculiar," she said after a while.

"What is?"

'There's a record of her because she's on the Medical School staff — you know, Hepatitis status, that kind of thing — but there's nothing about cancer."

Lenny was tired of being ignored. "Shall I carry on or not?"

"Please, Lenny."

Belinda left the terminal and came back to look. The undertakers were leaving, complete with extra passenger. She asked, "Do you mind if I get changed and come round and look. This is a fascinating case."

Hartmann didn't want fascinating, he wanted easy and quick. He also wanted to be left alone to his own incompetence, not constantly made to feel a prat by a registrar. Yet what could he say? It was a teaching hospital, after all. "Of course."

He turned to inspect the body a little more closely, afraid lest he should miss something, as Lenny began to progress the dissection. The whole of the liver was replaced by tumour; dead and dying grey-white tissue splash-painted with areas of haemorrhage and, in the liver particularly, small green patches. The wall of the stomach was covered with nodules of tumour, most about a centimetre in diameter, although one was significantly larger and measured nearly ten centimetres. Similarly the omentum — the sheet of fat which hangs from the lower border of the stomach — had been infiltrated so that it was thickened, stiff and solid. Beneath this, the coils of intestine also showed nodular tumours.

He knew that it wasn't ovarian and as soon as Belinda got there, she opined similarly. "That greenish staining looks like bile."

"Hepatocellular carcinoma?" he said quickly before she could, "Yes, that's what I was wondering." Primary cancer of the liver was the only type that produced bile.

"But there are also tumours on the intestinal wall — small intestine, too."

The small intestine — a rare site for tumours.

He nodded, as if understanding her consternation from the vantage of greater knowledge.

Lenny had been opening the chest. He took a steel tenon saw and began to cut through the ribs on the left hand side, starting at the bottom perhaps ten centimetres from the midline and working up and in so that at the clavicle the cut was adjacent to the sternum. He came round to the other side of the table and repeated the process on the right hand side. Then he lifted the bottom end of the sternum and began partly to pull and partly to try to cut the sternum off the underlying tissues.

Only it wouldn't come.

It ought to have been easy, the sack around the heart and the soft tissues in the middle of the chest coming away like sticky grey candyfloss.

Lenny looked up at Hartmann who was watching him. Lenny was sufficiently well trained to know that it was Hartmann's job if something untoward occurred; this, of course, suited Lenny and it was therefore one of the few rules he obeyed.

"What's up?" asked Hartmann.

"It won't come. There's something sticking it down."

Hartmann took the knife back and, grabbing the sternum in his right hand, began to cut at the tissues under it. The knife met fibrotic, almost solid tissue. He took a firmer grip of the handle and began to saw through it. Ten minutes later, the sternum came away at least and revealed what had glued it down so firmly. Hartmann could only stare at it.

The entire chest seemed filled with friable, mottled tissue laced with areas of fresh bleeding. The bag in which the heart was hung was encased in it and the lungs on either side were lost in it. A few pockets of fluid in irregular spaces were all that was left of the space around the lungs.

Her chest had become merely a box of tumour.

He heard Belinda mutter something beside him. It was only after a few seconds that he realized what she had said.

"Bloody hell."

*

It took Hartmann and Belinda an hour to take out the organ mass and a further hour to dissect the organs from it. Lenny retreated, claiming that it was Hartmann's job, given the extent of the cancer, and Hartmann couldn't really argue. Denny dropped by, taking a break from whatever mysterious tasks occupied his time and earned his wages, to whistle, much as he would have whistled at a mate with a penis of impressive size.

"Poor bitch," he offered but empathy was again absent from his voice.

The organs were now neatly arrayed on the dissection board, and on Hartmann's face was arrayed a look of deep bewilderment. Belinda stood beside him, trying to make some sense of it all.

Every single organ had some form of tumorous involvement. True, some had more than others, so that the lungs were effectively completely effaced as were the liver, ovaries and thyroid, while the kidneys, intestines, heart and uterus still retained their overall structure albeit liberally dotted with cancer. The brain was also affected, Hartmann's neat slices revealing a large mass of dead and dying tumour in the left hemisphere that measured eight centimetres across, another, smaller one in the right and two in the cerebellum.

One by one he had sliced into the organs and one by one had revealed a greater or less degree of malignancy. When he had opened the intestines — all ten metres of them — he had expected to find only surface involvement by tumour, spread from outside, but he had instead found the lining of both the large and small intestines carpeted with polypoid growths large and small. Nestling amongst which were no less than six cancers, two in the small intestine and four in the large.

The stomach contained three tumours and the lumen of the gullet was obliterated by a solid mass of cancerous tissue; these lesions rested on a curious, velvety-red surface which was quite unlike the usual appearance. Hartmann suspected that it represented some form of "field change," that all of the stomach and oesophageal lining was turning malignant.

Even the larynx contained scattered nodules that were almost certainly cancerous. The spleen, normally weighing between one and two hundred grams, was huge and clocked in at nearly two kilograms; its cut surface was speckled with white spots, some nearly a centimetre in diameter.

Hartmann had gone back to the body cavity and began to feel the dead, firm muscles and bones. It had not been long before he had felt a firm lump in the musculature of the right calf and, uncaring of the danger of a hosepipe down his trousers, he had incised the skin to reveal yet another tumour. In a similar fashion he had found two more muscle tumours and then gone to find that the right femur, right humerus, left side of the pelvis and left shoulder blade were all focally expanded; he had chipped away the surface bone to reveal yet more tumours.

The bone marrow, exposed by stripping off the front of the spinal column was pale grey and softly fluctuant; Hartmann could find no surprise within himself when he discovered this. He looked in the mouth and found extensive ulceration and Hartmann knew that its cause wasn't ill-fitting denturework.

"This is impossible." Belinda's remark was understandable but neither helpful nor, by definition, accurate. Hartmann had been afraid that she would show him up for a fool, but it was clear that this case was showing them both the limits of their wisdom. He knew that he was hopelessly lost but he had enough experience and enough innate wisdom to try to adopt a reasonable coping strategy.

First, run through the facts in your mind. Lay them out before you try to connect them. "Look," he said to Belinda. "Let's just start at the beginning. She was a girl in her early twenties. It's improbable but not impossible that she might develop cancer at that age, but the range of tumours she's likely to develop is limited. I wouldn't be surprised to see a thyroid tumour, or even some types of gynaecological malignancy. Other possibilities include lymphoma or leukaemia which may well affect this age group, bone cancers and a variety of soft tissue tumours."

"And brain tumours."

"And brain tumours. And, it would appear from macroscopic examination, we actually may well have those tumour types here."

"But she should have only one of them."

"And that's the problem. She hasn't just got one of them, or two of them. She's got all of them and more; tumours she shouldn't have developed for another fifty years — lung carcinoma, colorectal carcinoma, what looks like a liposarcoma."

Belinda was frowning intensely. "You don't suppose," she said tentatively, "that it's just one of them that's spread all over the place?" she asked.

There was a pause while Hartmann thought again about that possibility but, if he wasn't the best pathologist in the Royal College, he was good enough to know that wasn't the reason. He indicated the lining of the intestine; it was covered in a carpet of red growths like tropical sea anenomes. "Look at those adenomatous polyps. They're premalignant, suggesting she has a primary colonic carcinoma. Yet if you look in the breasts, both of them contain not only invasive tumours but also evidence of cancers that are still in-situ, yet to spread."

"Suggesting that the breast cancers are also primaries."

"Exactly. And then there's the spleen. I suppose it could be carcinoma from somewhere, but if I didn't know better, I'd say that has the classical look of lymphoma, wouldn't you?"

She was forced to admit that it did. "And there are about a dozen other findings that indicate multiple primaries," she added.

"Exactly."