No wonder the walls of the convent had seemed so welcoming.
Rizzoli sighed and turned to look at the road that stretched ahead. “Let’s go home,” she said.
“This diagnosis has me stumped,” said Maura.
She laid out a series of digital photographs on the conference room table. Her four colleagues did not so much as flinch at the images, for they had all seen far worse sights in the autopsy lab than these views of rat-bitten skin and angry nodules. They seemed far more focused on the box of fresh blueberry muffins that Louise had brought in that morning for case conference, an offering that the doctors were happily devouring, even as they stared at stomach-turning photos. Those who work with the dead learn to keep the sights and smells of their jobs from ruining their appetites, and among the pathologists now seated at the table was one known to be particularly fond of seared foie gras, a pleasure undimmed by the fact he dissected human livers by day. Judging by his ample belly, nothing ruined Dr. Abe Bristol’s appetite, and he happily munched on his third muffin as Maura set down the last of the images.
“This is your Jane Doe?” asked Dr. Costas.
Maura nodded. “Female, approximate age thirty to forty-five, with a gunshot wound to the chest. She was found about thirty-six hours after death inside an abandoned building. There was postmortem excision of the face, as well as amputations of the hands and the feet.”
“Whoa. There’s a sick boy for you.”
“It’s these skin lesions that stump me,” she said, gesturing to the array of photos. “The rodents did some damage, but there’s enough intact skin left to see the gross appearance of these underlying lesions.”
Dr. Costas picked up one of the photos. “I’m no expert,” he said solemnly, “but I’d call this a classic case of red bumps.”
Everyone laughed. Physicians flummoxed by skin lesions often resorted to simply describing the skin’s appearance, without knowing its cause. Red bumps could be caused by anything from a viral infection to autoimmune disease, and few skin lesions are unique enough to point to an immediate diagnosis.
Dr. Bristol stopped chewing his muffin long enough to point to one of the photos and say, “You’ve got some ulcerations here.”
“Yes, some of the nodules have shallow ulcerations with crust formation. And a few have the silvery scales you’d see in psoriasis.”
“Bacterial cultures?”
“Nothing unusual is growing out. Just Staph. epidermidis.”
Staph epi was a common skin bacteria, and Bristol merely shrugged. “Contaminant.”
“What about the skin biopsies?” asked Costas.
“I looked at the slides yesterday,” said Maura. “There are acute inflammatory changes. Edema, infiltration by granulocytes. Some deep micro-abscesses. There are also inflammatory changes in the blood vessels as well.”
“And you have no bacteria growing?”
“Both the Gram stain and Fite Faraco stains are negative for bacteria. These are sterile abscesses.”
“You already know the cause of death, right?” said Bristol, his dark beard catching the crumbs of his muffin. “Does it really matter what these nodules are?”
“I hate to think I’m missing something obvious here. We have no identification on this victim. We don’t know anything about her, except for the cause of death and the fact she was covered with these lesions.”
“Well, what’s your diagnosis?”
Maura looked down at the ugly swellings, like a mountain range of carbuncles across the victim’s skin. “Erythema nodosum,” she said.
“Cause?”
She shrugged. “Idiopathic.” Meaning, quite simply, cause unknown.
Costas laughed. “There’s a wastebasket diagnosis for you.”
“I don’t know what else to call it.”
“Neither do we,” said Bristol. “Erythema nodosum works for me.”
Back at her desk, Maura reviewed the typed autopsy report for Rat Lady, which she had dictated earlier, and felt dissatisfied as she signed it. She knew the victim’s approximate time of death, and the cause of death. She knew the woman was most likely poor, and that she had surely suffered from the humiliation of her appearance.
She looked down at the box of biopsy slides, labeled with the name Jane Doe and the case number. She pulled out one of the slides and slid it under the microscope lens. Swirls of pink and purple came into focus through the eyepiece. It was a hematoxylin and eosin stain of the skin. She saw the dark stipples of acute inflammatory cells, saw the fibrous circle of a blood vessel infiltrated by white cells, signs that the body was fighting back, sending its soldiers of immune cells into battle against … what?
Where was the enemy?
She sat back in her chair, thinking of what she’d seen on autopsy. A woman with no hands or face, mutilated by a killer who harvested identities as well as lives.
But why the feet? Why did he take the feet?
This is a killer who seems to operate with cool logic, she thought, not twisted perversions. He shoots to kill, using an efficiently lethal bullet. He strips the victim but does not sexually abuse her. He amputates the hands and feet and peels off the face. Then he leaves the corpse in a place where its skin will soon be gnawed away by scavengers.
It kept coming back to the feet. The removal of the feet was not logical.
She retrieved Rat Lady’s X-ray envelope and slid the ankle films onto the light box. Once again, the abrupt demarcation of severed flesh shocked her, but she saw nothing new here, no clues that would explain the killer’s motive for the amputation.
She took the films down, replaced them with the skull films, frontal and lateral views. She stood gazing at the bones of Rat Lady’s face, and tried to envision what that face might have looked like. No older than forty-five, she thought, yet already you have lost your upper teeth. Already, you have the jaw of an elderly woman, the bones of your face rotting from within, your nose sinking into a widening crater. And scattered across your torso and limbs are ugly nodules. Just a glance in the mirror would be painful. And then to step outside, into the eyes of the public …
She stared at the bones, glowing on the light box. And she thought: I know why the killer took the feet.
It was only two days before Christmas, and when Maura walked onto the Harvard campus, she found it almost deserted, the Yard a broad expanse of white, scarcely marred by footprints. She tramped along the walkway, carrying her briefcase and a large envelope of X rays, and could smell, in the air, the metallic tang of a coming snowfall. A few dead leaves clung, shivering, to bare trees. Some would view this scene as a holiday postcard with a Season’s Greeting caption, but she saw only the monotonous grays of winter, a season she was already weary of.
By the time she reached Harvard’s Peabody Museum of Archaeology, cold water had seeped into her socks and the hems of her pant legs were soaked. She stomped off the snow and walked into a building that smelled of history. Wooden steps creaked as she went down the stairwell to the basement.
The first thing she noticed, as she stepped inside the dim office of Dr. Julie Cawley, were the human skulls—at least a dozen of them, lining the shelves. A lone window, set high in the wall, was half covered by snow, and the light that managed to seep through shone down directly on Dr. Cawley’s head. She was a handsome woman, with upswept gray hair that looked pewter in the wintry light.
They shook hands, an oddly masculine greeting between two women.
“Thank you for seeing me,” said Maura.
“I’m rather looking forward to what you have to show me.” Dr. Cawley turned on a lamp. In its yellowish glow, the room suddenly seemed warmer. Cosier. “I like to work in the dark,” she said, indicating the glow of the laptop on her desk. “It keeps me focused. But is hard on these middle-aged eyes.”
Maura opened her briefcase and removed a folder of digital prints. “These are the photos I took of the deceased. I’m afraid they’re not very pleasant to look at.”
Dr. Cawle
y opened the folder and paused, staring at the photo of Rat Lady’s mutilated face. “It’s been a while since I’ve attended an autopsy. I certainly never enjoyed it.” She sat down behind the desk and took a deep breath. “Bones seem so much cleaner. Somehow less personal. It’s the sight of flesh that turns the stomach.”
“I also brought her X rays, if you’d rather look at those first.”
“No, I do need to look at these. I need to see the skin.” Slowly she flipped to the next photo. Stopped and stared in horror. “Dear god,” she murmured. “What happened to the hands?”
“They were removed.”
Cawley shot her a bewildered look. “By whom?”
“The killer, we assume. Both hands were amputated. So were parts of the feet.”
“The face, the hands, the feet—those are the first things I’d look at to make this diagnosis.”
“Which could be the reason why he removed them. But there are other photos in there that might help you. The skin lesions.”
Cawley turned to the next set of images. “Yes,” she murmured, as she slowly flipped through them. “This certainly could be …”
Maura’s gaze lifted to the row of skulls on the shelf, and she wondered how Cawley could work in this office, with all those empty eye sockets staring down at her. She thought of her own office, with its potted plants and floral paintings—nothing on the walls to remind her of death.
But Cawley had chosen to surround herself with the evidence of her own mortality. A professor of medical history, she was a physician as well as an historian, a woman who could read a lifetime’s worth of miseries etched in the bones of the dead. She could look at the skulls on her shelf and see, in each, a personal history of pain. An old fracture or an impacted wisdom tooth or a jawbone infiltrated by tumor. Long after the flesh melts away, the bones still tell their stories. And judging by the many photos of Dr. Cawley taken at archaeological dig sites around the world, she had been mining these stories for decades.
Cawley looked up from a photo of one of the skin lesions. “Some of these do bear a resemblance to psoriasis. I can see why it was one of the diagnoses you considered. These could also be leukemic infiltrates. But we’re talking about a great masquerader. It can look like many different things. I assume you did skin biopsies?”
“Yes, including stains for acid-fast bacilli.”
“And?”
“I saw none.”
Cawley shrugged. “She may have received treatment. In which case there’d be no bacilli still present on biopsy.”
“That’s why I came to you. Without active disease, without bacilli to identify, I’m at a loss as to how to make this diagnosis.”
“Let me see the X rays.”
Maura handed her the large envelope of films. Dr. Cawley carried them to a viewing box mounted on her wall. In that office cluttered with artifacts from the past—skulls and old books and several decades’ worth of photos—the light box stood out as a starkly modern feature. Cawley rifled through the X rays and finally slid one under the mounting clips.
It was a skull film, viewed face-on. Beneath the mutilated soft tissues, the bony structures of the face remained intact, glowing like a death’s head against the black background. Cawley studied the film for a moment, then pulled it down and slid on a lateral view, taken of the skull’s profile.
“Ah. Here we go,” she murmured.
“What?”
“See here? Where the anterior nasal spine should be?” Cawley traced her finger down what should have been the slope of the nose. “There’s been advanced bone atrophy. In fact, there’s almost complete obliteration of the nasal spine.” She crossed to the shelf of skulls and took one down. “Here, let me show you an example. This particular skull was exhumed from a medieval grave site in Denmark. It was buried in a desolate spot, far outside the churchyard. You see here, where inflammatory changes have destroyed so much bony tissue that there’s just a gaping hole where the nose would be. If we were to boil off the soft tissues from your victim there—” She pointed to the X ray “—her skull would look very much like this one.”
“It’s not postmortem damage? Could the nasal spine have been cracked off when the face was excised?”
“It wouldn’t account for the severity of changes I see on that X ray. And there’s more.” Dr. Cawley set down the skull and pointed to the film. “You’ve got atrophy and recession of the maxillary bone. It’s so severe that the front upper teeth have been undermined and have fallen out.”
“I’d assumed it was due to poor dental care.”
“That may have contributed. But this is something else. This is far more than just advanced gum disease.” She looked at Maura. “Did you do the other X-ray projections I suggested?”
“They’re in the envelope. We did a reverse Waters shot as well as a periapical series to highlight the maxillary landmarks.”
Cawley reached inside and pulled out more X rays. She clipped up a periapical film, showing the floor of the nasal cavity. For a moment she said nothing, her gaze transfixed by the white glow of bone.
“I haven’t seen a case like this in years,” she murmured in wonder.
“Then the X rays are diagnostic?”
Dr. Cawley seemed to shake herself from her trance. She turned and picked up the skull from her desk. “Here,” she said, turning the skull upside down to show the bony roof of the hard palate. “Do you see how there’s been pitting and atrophy of the alveolar process of the maxilla? Inflammation has eaten away this bone. The gums have receded so badly that the front teeth fell out. But the atrophy didn’t stop there. Inflammation continued to chew away at the bone, destroying not just the palate, but also the turbinate bones inside the nose. The face was literally eaten away, from the inside, until the hard palate perforated and collapsed.”
“And how disfigured would this woman have been?”
Cawley turned and looked at the X ray of Rat Lady. “If this were medieval times, she would have been an object of horror.”
“Then this is enough for you to make a diagnosis?”
Dr. Cawley nodded. “This woman almost certainly had Hansen’s disease.”
THIRTEEN
The name sounded innocuous enough to those who did not recognize its meaning. But the disease had another name as well, a name that rang with ancient echoes of horror: leprosy. It conjured up medieval images of robed untouchables hiding their faces, of the shunned and pitiful, begging for alms. Of leper’s bells, tinkling to warn the unwary that a monster approaches.
Such monsters were merely the victims of a microscopic invader: Mycobacterium leprae, a slow-growing bacillus that disfigures as it multiplies, rippling the skin with ugly nodules. It destroys nerves to the hands and feet so that the victim no longer senses pain, no longer flinches from injury, leaving his limbs vulnerable to burns and trauma and infection. With the passage of years, the mutilation continues. The nodules thicken, the bridge of the nose collapses. The fingers and toes, repeatedly injured, begin to melt away. And when the sufferer finally dies, he is not buried in the churchyard, but is banished far beyond its walls.
Even in death, the leper was shunned.
“To see a patient in such an advanced stage is almost unheard of in the U.S.,” said Dr. Cawley. “Modern medical care would arrest the disease long before it caused this much disfigurement. Three-drug therapy can cure even the worst cases of lepromatous leprosy.”
“I’m assuming this woman has been treated,” said Maura. “Since I saw no active bacilli in her skin biopsies.”
“Yes, but treatment obviously came late for her. Look at these deformities. The loss of teeth and the collapse of facial bones. She was infected for quite some time—probably decades—before she received any care.”
“Even the poorest patient in this country would have found treatment.”
“You’d certainly hope so. Because Hansen’s disease is a public health issue.”
“Then the chances are this woman was an immigra
nt.”
Cawley nodded. “You can still find it among some rural populations around the world. The majority of cases worldwide are in only five countries.”
“Which ones?”
“Brazil and Bangladesh. Indonesia and Myanmar. And, of course, India.”
Dr. Cawley returned the skull to the shelf, then gathered up the photos on her desk and shuffled them together. But Maura was scarcely aware of the other woman’s movements. She stared at the X ray of Rat Lady, and thought of another victim, another death scene. Of spilled blood, in the shadow of a crucifix.
India, she thought. Sister Ursula worked in India.
Graystones Abbey seemed colder and more desolate than ever when Maura stepped through the gate that afternoon. Ancient Sister Isabel led the way across the courtyard, her L. L. Bean snow boots peeking out incongruously from beneath the hem of her black habit. When winter turns brutal, even nuns rely on the comfort of Gore-Tex.
Sister Isabel directed Maura into the Abbess’s empty office, then she vanished down the dark hallway, the clomp-clomp of her boots trailing a fading echo.
Maura touched the cast-iron radiator beside her; it was cold. She did not take off her coat.
So much time passed that she began to wonder if she had been forgotten, if the antique Sister Isabel had simply shuffled on down the hall, her memory of Maura’s arrival fading with each step. Listening to the creaks of the building, to the gusts rattling the window, Maura imagined spending a lifetime under this roof. The years of silence and prayer, the unchanging rituals. There would be comfort in it, she thought. The ease of knowing, at each dawn, how the day will go. No surprises, no turmoil. You rise from bed and reach for the same clothing, kneel for the same prayers, walk the same dim corridors to breakfast. Outside the walls, women’s hems might rise and fall, cars might take on new shapes and colors, and a changing galaxy of movie stars would appear and then vanish from the silver screen. But within the walls, the rituals continue unchanging, even as your body grows infirm, your hands unsteady, the world more silent as your hearing fades.
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