Robin Cook - Vital Signs
Prologue
February 16, 1988
The infecting bacteria came in a swift gush as if flushed from a sewer. In an instant, several million slender, rod-shaped microorganisms filled the lumen of the fallopian tubes. Most were grouped in small, tight clumps. They settled against the velvety convolutions of the mucosa, nestling in the warm, fertile valleys, absorbing the abundant nutrients and expelling their own foul excretions.
The delicate cells lining the interior of the oviducts were helpless in the face of the sudden invading horde. The putrid waste of the bacteria-caustic proteins and greasy fats-burned like acid, resulting in instant destruction of the fine cilia whose nor malfunction was to move an egg toward the uterus.
The tubular cells released their defensive and messenger chemicals, signaling the body for help. Unfortunately, the defensive secretions had no effect on the bacteria, whose membranes were protected by a brownish waxy envelope of lipid.
Medical students fresh from their microbiological labs would have recognized the bacteria--or so they would have thought. The fatly bacterial cell walls were "acid fast," capable of absorbing certain stains and resisting decolorizing with acid alcohol. The medical students would have cried in unison, "Tuberculosis, " with a self-congratulatory sense of satisfaction.
Tubercular or not, as far as the tubal cells were concerned, any kind of invading bacteria meant trouble. The messenger chemicals that the cells had released initiated the complex immunological defense against foreign invaders which had evolved over the entire billion-year evolution of earthly life.
The chemicals released initiated a change in the local blood vessels. The blood flow increased and opened up tinyfenestrations, releasing Plasma into the tissue. Specialized, first-line-of-defense cells called granulocytes migrated from the bloodstream directly into the bacterial horde. These cells released more chemicals, including potent enzymes. They also combated the bacteria directly.
But for them it was a kamikaze exercise---after releasing their granules, nearly all the granulocytes perished.
Soon, larger cells called macro phages answered the chemical call, mobilizing themselves from lymph nodes and the bone marrow.
They too passed through the pores of the capillaries to join the melee. They were more successful than the granulocytes in engulfing some of the bacteria. They also released chemicals into the developing pus, which was now taking on a greenish cast.
Within seven hours lymphocytes began to accumulate, marking the beginning of another level of immunological defense. Since this particular type of bacteria had not been encountered before, there were no specific antibodies circulating. But the process to make them had begun. T-lymphocytes massed and underwent chemical induced alterations. They also stimulated the arrival of more macro phages which in turn stimulated more T-cell aggregation in an ever-increasing spiral of cellular activity.
After twenty-four hours, the balance of the struggle had already tipped away from the bacteria. The tubular cells were winning but the victory was Pyrrhic. Vast areas of the delicate mucosal lining of the fallopian tubes had been destroyed by the immunological reaction. Extensive scarring was inevitable. Interference with the blood flow added to the injury. And on top of that, the remaining bacteria and their waste continued to stimulate the immune system's response. The body persisted in amassing more cellular troops, unaware that the battle had been won. Macrophages continued to arrive, and their activity caused more destruction. In their frenzy, some of the cells underwent nuclear division without subsequent cellular division, resulting in giant cells with multiple nuclei.
Again, the medical students would have smiled knowingly if they'd had a chance to view this sequence through the lens of a microscope. They would have nodded with appreciation at the distorted architecture of the developing granuloma.
This cellular drama continued to play out over several weeks within the dark recesses of thirty-one-year-old Rebecca Ziegler's womb. Rebecca her se had no idea of frantic chemical battles being waged within her body, nor of the resultant cellular destruction.
There had been a few hints: subtle changes in her vital signs in the form of a low-grade fever and a mildly elevated pulse She had even experienced some cramps, lower abdominal tenderness, and a mild vaginal discharge, but none of these signs and symptoms seemed cause for concern. Even a mildly abnormal Pap smear which had caused her momentary worry had been proven to have been perfectly normal after all.
Rebecca ignored these petty maladies. After all, everything else in her life was wonderful, Six months earlier she'd married, to her mother's relief and her life had taken on new meaning. She'd even accepted a new Job as one of the youngest litigators for aprestigious Boston law firm Everything was perfect, and she was not about to let some mild physical complaints mar her mood Yet there was more to this episode than Rebecca could have known. The bacteria had started a chain of events that went beyond the immunological. The consequences were destined to come back to haunt her, to rob her of her happiness, and eventually, indirectly, to kill her.
February 21,1988 An agonizing screech of metal scraping against metal jangled Marissa Blumenthal's already frayed nerves as the aging MBTA subway train strained to navigate the sharp turn into the Harvard Square station in Cambridge, Massachusetts. Marissa closed her eyes for a moment in a vain attempt to shield herself from the grating racket as she clutched an upright pole. She wanted to get out of the train. Besides peace and quiet, she needed fresh air.
Wedged among a crowd of six-foot-plus giants, five-foot Marissa felt more claustrophobic than usual. The air in the subway car felt oppressively warm. It was a rainy February day and the damp smell of moist wool added to her discomfort.
Like everyone else in the train, Marissa tried to avoid eye contact with the people pressed up against her. It was a mixed crowd. Harvard Square attracted both ends of the spectrum. To Marissa's right was an Ivy League lawyer-type with a black ostrich briefcase, his nose buried in a,crisply folded copy of The Wall Street Journal. Directly in front of her was a fetid breathed skinhead, outfitted in a denim jacket from which the sleeves had been cut. He had clumsily tattooed swastikas on each knuckle of his hands. To her left was a massive black man with a ponytail of dreadlocks, wearing gray sweats. His sunglasses were so dark that Marissa could not see his eyes as she furtively glanced in his direction.
With a final lurch that all but sent Marissa to the floor, the train stopped and the doors slid open. Breathing a sigh of relief, Marissa stepped out onto the platform. Normally she would have driven her car from her office and left it under the Charles Hotel, but she wasn't sure how she would be feeling after her minor surgical procedure, so she'd decided it was more prudent to take the T. There had been talk of her having some kind of sedative or intravenous painkiller, an idea that Marissa was not averse to.
She freely admitted that she was not good with pain. If she was groggy after the anesthesia, she thought it best not to drive.
Marissa hurried past a trio of street musicians playing for commuters' donations and quickly went up the stairs to the street. it was still raining so she paused briefly to raise her folded umbrella.
Marissa buttoned her trench coat and held her umbrella tight as she traversed the square and headed up Mount Auburn Street.
Sudden gusts of wind foiled her attempt to stay dry; by the time she reached the Women's Clinic at the end of Nutting Street, a plethora of raindrops were sprinkled across her forehead like beads of perspiration. Beneath the glass-enclosed walkway that spanned the street and connected the main building of the clinic to its overnight ward and emergency facilities, Marissa shook her umbrella and folded it closed.
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br /> The clinic building was a postmodern structure, built of red brick and mirrored glass, which faced a bricked courtyard. The main entrance was off the courtyard and was reached by a wide run of granite steps.
Taking a deep breath, Marissa climbed the front steps. Although as a physician she was accustomed to entering medical facilities, this was the first time she was doing so as a patient, coming in not just for an examination but for surgery. The fact that it was minor surgery had less of a mitigating effect than she'd imagined. For the first time Marissa realized that from a patient's point of view, there was no such thing as "minor" surgery.
Only two and a half weeks earlier Marissa had climbed the same steps for a routine annual Pap smear only to learn a few days later that the results were abnormal, bearing the grade CIN #1. She'd been genuinely surprised, having always enjoyed perfect health. Vaguely she'd wondered if the abnormality had anything to do with her recent marriage to Robert Buchanan. Since their wedding, they had certainly been enjoying the physical side of their relationship a great deal.
Marissa grasped the brass handle of the massive front door and stepped into the lobby. The decor was rather stark although it reflected good taste and certainly money. The floor was surfaced in dark green marble. Ficus trees in large brick planters lined the windows. In the middle of the room was a circular information booth. Marissa had to wait her turn. She unbuttoned her coat and shook the moisture from her long brown hair.
Two weeks previously, having received the surprising result of the Pap smear, Marissa had had a long phone conversation with her gynecologist, Ronald Carpenter. He had strongly recommended the colposcopy-biopsy procedure.
"Nothing to it," he'd said with conviction.
"Piece of cake, and then we know for sure what's going on in there. It's probably nothing. We could wait for a while and do another smear, but if it were my wife, I'd say do the colposcopy. All that means is looking at the cervix with a microscope."
"I know what a colposcopy is," Marissa had told him.
"Well, then, you know how easy it is," Dr. Carpenter had added.
"I'll give the old cervix a good look, snip out a tiny piece of anything suspicious, and that will be it. You could be outta here in an hour. And we'll give you something in case there's any pain. In most centers they don't give any analgesia for biopsies, but we're more civilized. It's really easy. I could do it in my sleep."
Marissa had always liked Dr. Carpenter. She appreciated his offhand, easygoing manner. Yet his attitude about a biopsy made her appreciate the fact that surgeons viewed surgery in a fundamentally different way than patients did. She wasn't concerned about how easy the procedure was for him. She was concerned about its effect on her. After all, above and beyond the pain, there was always the possibility of a complication.
Yet she was reluctant to procrastinate. As a physician, she was well aware of the consequences of putting off a biopsy. For the first time, Marissa felt medically vulnerable. There was a remote but real possibility that the biopsy might prove to be positive for cancer. In that case, the sooner she knew the answer, the better off she'd be.
"Day surgery is on the third floor," the receptionist said cheerfully in response to Marissa's question. "just follow the red line on the floor."
Marissa looked down at her feet. A red, a yellow, and a blue line ran around the information booth. The red line led her to the elevators.
On the third floor, Marissa followed the red line to-a window with a sliding glass panel. A nurse dressed in a standard white uniform opened the panel as Marissa approached.
"I'm Marissa Blumenthal," Marissa managed. She had to clear her throat to get it out.
The nurse found her folder, glanced at it briefly to see if it was complete, then extracted a plastic ID bracelet. Reaching across the countertop, the nurse helped Marissa secure the bracelet.
Marissa found the procedure unexpectedly humiliating. From about the third year in medical school, she'd always felt in control in a hospital setting. Suddenly the tables were turned. A shiver of dread passed through her.
"It will be a few minutes," the nurse intoned. Then she pointed to some double doors.
"There's a comfortable waiting room just through there. Someone will call you when they are ready." The glass panel slid shut.
Dutifully Marissa went through the doors into a large, square room, furnished in a nondescript modern style. About thirty people were waiting. Marissa felt the stare of silent eyes as she self-consciously hurried to an empty seat at the end of a couch.
There was a view of the Charles River across a small green park. Silhouetted against the gray water were the leafless skeletons of the sycamore trees that lined the embankment.
By reflex, Marissa picked up one of the glossy-covered magazines from the side table and absently flipped through the pages.
Surreptitiously she glanced over the top of the magazine and was relieved to see that the eyes of the other people in the room had gone back to their own magazines. The only sound was of pages being turned.
Marissa stole quick glances at some of the other women, wondering what they were there for. They all seemed so calm. Surely she couldn't be the only one who was nervous.
Marissa tried to read an article on upcoming summer fashion trends, but she couldn't concentrate. Her abnormal Pap smear seemed like a hint of internal betrayal: a warning of what was to come. At thirty-three years old, she had been having the barest exterior reminders of getting older, like the fine lines appearing at the outer corners of her eyes.
Focusing for the moment on the many ads that filled the women's magazine in her hands, Marissa gazed at the faces of the sixteen- and seventeen-year-olds who populated them. Their youthful, b1cmish-free faces seemed to mock her and make her feel old beyond her years.
What if the biopsy was positive? What if she had cancer of the cervix? It was rare but not unknown in women her age. Suddenly the possibility bore down on Marissa with a crushing intensity.
My God! she thought. If it was cancer, she might have to have a hysterectomy, and a hysterectomy would mean no children!
A dizzy feeling spread through Marissa, and the magazine in her hands momentarily blurred. At the same time her pulse began to race. The thought of not having children was anathema to her.
She'd married only six months previously, and although she hadn't planned on starting a family immediately, she had always known that children would eventually be a big part of her life. If it turned out that she could not have children, she hated to consider the consequences, both for herself and for her husband.
And until that very moment, waiting for the biopsy that Dr.
Carpenter said would be "a piece of cake," she'd never given the possibility serious thought.
All at once Marissa felt hurt that Robert had not been more concerned and that he had taken her at her word when she'd said she'd be perfectly fine going to the clinic by herself Looking around the room again, Marissa saw that most of the other patients were accompanied by their spouses or boyfriends.
"You're being ridiculous," Marissa silently chided herself as she tried to keep her emotions in check. She was surprised and a little embarrassed. It was not like her to be so hysterical. She liked to think she wasn't easily upset. Besides, she knew that Robert couldn't have come with her even if he'd wanted to. That morning; he had an important meeting of the executive staff of his health care management, investment, and research company. It was a critical meeting that had been planned months in advance.
"Marissa Blumenthal!" a nurse called.
Marissa jumped up, placed the magazine on the side table, and followed the nurse down a long, blank white corridor. She was shown into a changing room with an inner door opening into one of the procedure rooms. From her vantage point in the changing area, Marissa could see the table with its gleaming, stainless steel stirrups, "Just to be on the safe side," the nurse said as she twisted Marissa's wrist to check her ID. Satisfied she had the right patient, she patted
some clothes on a bench and added: "Slip into this Johnny, slippers, and robe and hang your clothes in the closet. Any valuables can be locked in the drawer, When you're done, go in and sit on the examining table." She smildd. The woman was professional, but not without warmth. She closed the door to the hall behind her.
Marissa stepped out of her clothes. The floor was cold on her bare feet. As she struggled to tie the straps of the Johnny behind her, she acknowledged how much she liked the staff at the Women's Clinic, from the receptionists to her doctor. But the main reason she patronized the clinic was because of its private status and the consequent confidentiality it had to offer. Now that she was having a biopsy, she was even more thankful for her choice. Had she gone to any one of the major Boston hospitals, especially her own hospital, the Boston Memorial, she would have undoubtedly come in contact with people she knew.
Marissa had always been careful to keep her private life private.
She never wanted personal matters like birth control, annual pelvic exams, a couple of episodes of cystitis and the like to be topics of gossip with her colleagues. And even if people didn't talk, she did not want to worry about passing her GYN man in the hospital corridor or in the hospital cafeteria.
Robin Cook 1990 - Vital Signs Page 1