The Anatomy of Deception

by Lawrence Goldstone

  “Quite a bounty, eh?” he exulted, a wide smile disappearing under the ends of his mustache. “Who shall be first?” He moved to the nearest chest. “Let’s start with our carpenter.” He opened the top to reveal a bald man of about forty, heavily muscled about the arms. Three of us lifted him out of the ice onto a wheeled table and rolled him into the autopsy room.

  After the carpenter had been transferred to a postmortem table, the Professor assigned tasks. “Who’ll take notes?” he asked. “Turk … no, you observe. Corrigan. You get the chore.” Corrigan, a stocky, goggle-eyed, bandy-legged young man from South Philadelphia, was eerily reminiscent of a bulldog. He possessed the talent to be a first-rate physician but his dedication was suspect. He had taken notes just two weeks before, and assigning him the tedious chore again so soon was the Professor’s way of chiding him to greater application.

  As Corrigan sulked off toward the desk, Turk cast a grin his way. “Be sure to form your letters clearly,” he called.

  The Professor laughed and the rest of us chuckled as well. He rarely tolerated sarcasm in anyone else, but seemed to give Turk extra latitude. Perhaps he admired, as I did, Turk’s rise from poverty. “Simpson,” the Professor went on, “you will handle weights and measures, and Carroll will assist.”

  Simpson and I were almost always given the most responsible tasks. I was senior in experience, with almost five years in practice, and Simpson was without question the most devoted and hardworking young physician I had ever encountered. Fully cognizant of the risk the Professor had taken in including her on the staff, she seemed determined to leave not a scintilla of doubt that his decision had been the correct one. She was a square-faced, slightly thickset woman, three years my junior. Her speech, while lacking the lilt of the upper classes, was precise and well enunciated, indicating good schooling and, I assumed, an upbringing to match.

  When we had all taken our places, the Professor doffed his coat, donned a heavy apron, removed the appropriate implements from the cabinet, and strode to the body. The jauntiness he had exhibited earlier had vanished, replaced by self-assured professionalism.

  “We have here what you all can see is a large, powerfully built man, who the note says is German by extraction and was a carpenter by trade. He was admitted to the ward Wednesday last complaining of a cough and swelled feet. Chest measured eighty centimeters, with two-to-five centimeter expansion. Both sides functioned equally, percussion over lungs was normal, and there was nothing special on auscultation.

  “After admission, he grew steadily worse, spending most of his time sitting up in bed to ease his breathing. Cough became hacking with expectoration of a bright red color and like currant jelly, dyspnea increasing. Feet became increasingly edematous, expectoration bloody, dyspnea exaggerated. Three nights ago, he became almost insensible with a highly weakened pulse. He was briefly roused with stimulants, but died late Tuesday.”

  The Professor grasped the anatomist’s scalpel, larger and heavier than its surgical cousin. “We shall begin by opening the thorax.” Starting at each armpit, the Professor made a deep incision diagonally downward, so that they met at the sternum. He worked smoothly and quickly, the lines straight and true like a draftsman’s. There was a soft hiss as gases were released from the body, and the smell became almost overpowering. Each of us tried to remain stoic, but only the Professor seemed genuinely immune to the stench.

  From this juncture, the Professor made a third incision down through the abdominal wall to just above the pubic bone, bypassing the umbilicus, leaving a Y-shaped cut. He then peeled back a fold of skin to either side of the rib cage and one over the face. The carpenter had been dead for thirty-six hours. That, combined with lying in the ice, kept the flow of blood minimal, although it was sufficient to cover the Professor’s hands and wrists. What fluid did escape, I quickly sponged into the channels of the autopsy table.

  While the Professor rinsed his hands after the skin had been cleared, I grasped a set of rib cutters, which resembled large garden pruning clippers. I cut through the ribs at the far side of both lungs, just under the skin fold, each snap of the cutters making the sound of a breaking twig. When the ribs were free, the Professor removed the anterior chest wall to expose the organs underneath. From here, most anatomists used the Rokitansky method, extracting all the organs simultaneously after cutting off their connections to the body, but the Professor, although he had studied with Rokitansky at the Allgemeine Krankenhaus in Vienna, preferred the Virchow technique, removing the organs one at a time. Of course, he had studied with Virchow as well.

  “The body presents the appearance of a man dead of heart disease,” he began, as Corrigan entered the data into a journal. “There is a small amount of fluid in the abdomen.” Using a siphon, I drew off additional fluid in the lining over the lungs and heart, placing each in a graduated cylinder, which Simpson measured and noted.

  “In the right pleura, sixty ounces of clear serum, thirty ounces in the left, and eight ounces in the pericardium,” she reported. The Professor then severed the coronary arteries, freeing the heart, which Simpson removed from the chest cavity and placed on the scale.

  “Heart is large,” she said. “Seven hundred ten grams.” The heart was brought to an examining table and the Professor lanced it open. He spoke continuously as he cut, unmindful of the blood and other sera that once more drenched his bare hands, Corrigan scribbling furiously to get it all down.

  “Right chamber distended with large, jellylike clots. Ventricle dilated, measuring twelve centimeters from pulmonary ring to apex. Tricuspid orifice dilated fifteen centimeters in circumference. Segments of heart healthy, pulmonary valves normal. Left auricle large and contains blood, with clots. Left ventricle dilated and contains gelatinous clots. Those about the trabecula”—he indicated the partition that separates auricle from ventricle—“are colorless.”

  The Professor instructed Simpson to measure each chamber and the connecting valves, with the measurements then recorded in the journal. He noted where muscles were fibroid or pale in color or valves thickened at the edges. When the examination of the heart was complete, it was left on the table and the Professor removed each lung, one hand at the top, the other at the bottom, and repeated the dissection process. He observed that in both were large spots of apoplexy—hemorrhaging—and the anterior borders were emphysematous. Tissue sections presented coarse appearance of brown atrophy. After the lungs, he examined the bowels, kidneys—on which there were several cysts—liver, and spleen.

  The next step was to remove the brain, a delicate operation that only the most skilled anatomist could perform without mishap. Unfixed brain tissue has the consistency of gelatin and is notoriously difficult to handle. It had taken me months, but I finally mastered the technique and was now the only member of the staff to whom the Professor would delegate the task. After my first success, Turk had proclaimed me “Lord of the Runny Eggs.”

  I made a transverse incision at the back of the head from ear to ear across the brain stem, then separated the scalp from the underlying skull and pulled it forward. After utilizing a bone saw to score the calvaria—the cap of bone at the top of the skull—I employed a skull chisel, known as a “Virchow skull-breaker,” to remove it. I then moved with great care to gently lift the brain out of the cranial vault. My hands were soaked with perspiration and my clothes clung to me in the still air, making delicate movement laborious. I managed to remove the brain, which, as Turk had so aptly noted, felt like a mass of undercooked eggs, and placed it in a large jar of formalin fixative. After soaking for a moment, the brain tissue coagulated and was removed to a table and sliced for examination.

  “The brain, as we would have expected,” said the Professor after taking some cross sections, “presents nothing abnormal. The arteries at the base are opaque, but not rigid.”

  The remainder of the autopsy went quickly. The intestines were opened with an enterotome, a large specialized pair of shears. The major blood vessels were examined, but
nothing further of interest was discovered.

  When the examination was completed, ninety minutes after we began, the Professor washed his hands in the sink and then returned to the table. “Well, not too much question of what did this fellow in, eh?”

  Those of us familiar with the Professor’s teaching methods knew not to answer too hastily, but Farnshaw, four months removed from Harvard, rashly offered, “No, sir. Hypertrophy.” Farnshaw was tall, like Turk, with a smooth, clean-shaven face, and the innocence that is the inevitable result of an upbringing in which wealth is utilized to insulate life’s many pitfalls. So ingenuous was Farnshaw, however, that it was impossible not to feel affection for him. That he constantly stumbled in his barefaced attempts to prove himself worthy of our professional respect endeared him to us all the more. He was not, it must be said, a bad doctor, simply unseasoned, like newly hewn poplar.

  “Indeed,” replied the Professor. “An enlarged heart. Now, Farnshaw, this chap entered the hospital in relatively decent shape. Some coughing, but no evidence of advanced disease. What might have been done for him to prevent this unfortunate result?”

  “Digitalis,” replied Farnshaw triumphantly. My gaze met Simpson’s for a moment and her eyes rolled upward. Digitalis, derived from the otherwise poisonous purple foxglove, was known to strengthen contraction of the heart muscle, slow the heart rate, and help eliminate fluid from body tissues. It had been popular for a century and was prescribed by almost every physician in the nation for almost every heart problem. Every physician except the Professor, that is.

  “Simpson,” said the Professor, “you do not seem to agree.”

  “No, sir,” she answered, coughing slightly from being caught in the act. “I do not see how digitalis would have alleviated the symptoms or provided a cure.”

  “What then, Simpson?”

  Simpson considered this for a moment but finally admitted that she could think of no treatment that would have been effective. Such a response might have been treated harshly by many who taught medicine—doctors were supposed to have a response for everything—but the Professor preferred no answer to an incorrect one, and so merely nodded and moved on.

  “How about you, Turk?”

  “Perhaps showing him Farnshaw’s fee would have shocked him back to health,” Turk replied.

  “Ha! Quite right, Turk.” The Professor chortled. “That is one aspect of medical education that Harvard does not ignore.” He turned to the unfortunate Bostonian. Farnshaw’s face had gone a deeper red than his hair. “Digitalis would no more have prolonged this man’s life, Dr. Farnshaw, than would standing on his head. There was nothing we could have done for this man short of manufacturing him a new heart.”

  The Professor began to pace about the room, the fingers of his right hand tapping into his left. “All we know here, Farnshaw, is that we don’t know. We have permutated disparate pieces of data, but can come to no definitive conclusion. This patient died with all the symptoms of chronic coronary valve disease, but we find no affection of the valves and only moderate arterial degeneration. The kidneys are not especially fibroid and there was not sufficient pulmonary distress to account for the hypertrophy and dilation of the heart.”

  The Professor returned to his place at the center of the table and gestured at the cadaver, hand opened, palm up. “So what do we do, Farnshaw, when faced with a mystery?”

  As so often occurs in youth, Farnshaw’s reckless enthusiasm had been supplanted by abashed reticence.

  “After we have recorded each bit of data, no matter how seemingly inconsequential or tangential to the case,” expounded the Professor, now addressing all of us, “we form hypotheses and then pursue and test each one without prejudice or preconception until it is disproved. We distrust coincidence.

  “In this case,” the Professor continued, “there is evidence that circumstances that tend to produce and maintain a high degree of tension in the arterial system may lead to hypertrophy and dilation. Here, we have a subject whose occupation often involved intense exertion, and who had no history of syphilis, so it may be possible to connect his habits to the life of the disease. Still, as we cannot definitively account for the hypertrophy, we will simply chronicle the evidence so that we may compare it to similar instances in the future and seek correlations that may lead us to solve this riddle.”

  “Not a very satisfying conclusion,” remarked Turk.

  “On the contrary,” replied the Professor. “We have discovered a case whose particulars do not correspond to accepted data, an illness or condition from which this man died that is not yet recorded in the literature. What I see here, Turk, is an opportunity, and hardly unsatisfying.”

  “Of course, Doctor,” said Turk. “As you say.”

  “You are a good doctor, Turk, but I’m not sure that research is your métier,” observed the Professor. “Perhaps you and Farnshaw should join in private practice. That way you may partake of those legendary Harvard fees.”

  Farnshaw again reddened, but Turk guffawed. “An excellent suggestion,” he replied cheerily.

  We all grinned, grateful for the break as the Professor strode over to check Corrigan’s notes. As Simpson and I made to deposit tissue samples in specimen jars and return the removed organs to the body, I noticed her eyes on me, but her gaze flitted quickly away. For a time, Charlie had been responsible for putting things back in what order he could, and then stitching up the cadavers before burial. But Charlie, who had been known to tipple the alcohol in the specimen jars, was not always reliable. On one occasion, some months ago, a male cadaver ordered exhumed because of suspicion of foul play was found by Formad to have three livers. We now performed the chore ourselves.

  After all was in order and the carpenter had been returned to the ice chest, the Professor moved to the next subject that Charlie had marked for him. This was the male Negro.

  Following the same procedure, it soon became apparent from an extensively cirrhotic liver that the man had died of alcohol poisoning. The case was undistinguished except the Professor declared that the condition of the left lung was extraordinary. “I have never seen an organ so infiltrated with bloody serum.” The fluid had a uniform purplish red, viscous appearance. The Professor was at a loss to account for it, except to hypothesize that the subject, under the influence of drink, had gone to sleep coiled on his left side so that, while he was senseless, his gradually weakened heart propelled feeble charges into the pulmonary artery. By hypostasis, an increasing volume had reached the left lung until a state of extreme congestive edema was produced.

  For our third specimen, the Professor chose the elderly woman with stomach cancer. Her case was equally unremarkable and, when we had finished with her, it was only two o’clock. “Well,” said the Professor eagerly, “it looks as if we’ll have time for another.”

  As the rest of the group returned the dead woman to the ice, I remained in the dissecting room to wipe down the table more thoroughly. When I got to the mortuary door, the Professor was standing at the chest that held the girl found dead on the streets of unknown causes.

  “A bit of a mystery here, eh?” he said, and swung open the lid.

  Only because I was standing away did I notice Turk’s reaction. For an instant, his body stiffened and his gaze froze on the cadaver. I stepped in hastily to see what had caused his reaction, and got a brief glimpse of a young, light-haired woman of perhaps twenty years of age. Although she had been dead for some days, she looked nothing like the street urchins we generally encountered. She had a beautiful figure and what seemed to have been clear, unblemished skin, marred only with distinct bruising to the upper left arm and milder trauma at the lower abdomen. As I leaned forward for a closer look, the Professor slammed the lid shut. The crack of metal on metal reverberated through the room.

  “I’ve changed my mind,” he said quickly. He took a deep breath and then smiled stiffly. “We’ve been at this for quite some time. No need to overdo, eh?”

  Turk had recovered his
equilibrium, but remained staring, his brow furrowed, at the closed cover of the chest.

  CHAPTER 2

  WE RETURNED TO THE DISSECTING room to clean up and put things in order for Charlie. When we were about to leave, we waited for the Professor to lead us back across to University Hospital. Instead he said somewhat brusquely, “I wish to remain here for a bit and check some notes. I’ll see you all tomorrow. Thank you for your participation.”

  I lingered briefly, wondering if the Professor would wish to talk with me privately, as he often did. But he had busied himself poring through an old journal, so I made for the door.

  Turk was waiting for me outside, hands in his pockets, his weight on his left leg, the very picture of ease. “Well, Carroll,” he said, smiling affably to reveal a set of uneven teeth, “it seems that we’re all free for the evening.”

  “Your wish granted,” I replied. “Now you can go to the theater.”

  “What about you?” he asked. “You’re not going to spend the night prowling the wards, are you?”

  “I haven’t decided,” I told him, although that was probably my intention. There was always something more to do and, in truth, I lacked an alternative.

  “Well, then, why don’t you join me?”

  “At the theater?” I wondered briefly at the coincidental timing of Turk’s intriguing reaction to the young girl in the mortuary and his unexpected cordiality, but could not see how the two could be related. Perhaps it was simply that my overtures had borne fruit after all.

  “Absolutely. I’ll call for you at seven-thirty.”

  As Turk ambled back to the hospital, I turned to see Simpson standing next to me. A strand of hair had fallen out from underneath her cap, and she absently shoved it back into place. “So, you’re spending the evening with the mysterious Turk?” She watched him recede down the path. “I suspect you will never be seen again in this hemisphere.”