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.