by Nicholas Lim
Contents
Cover
Copyright
Dedication
Acknowledgements
Preface
Chapter 1
Chapter 2
Chapter 3
Chapter 4
Chapter 5
Chapter 6
Chapter 7
Chapter 8
Chapter 9
Chapter 10
Chapter 11
Chapter 12
Chapter 13
Chapter 14
Chapter 15
Chapter 16
Chapter 17
Chapter 18
Chapter 19
Chapter 20
Chapter 21
Chapter 22
Chapter 23
Chapter 24
Chapter 25
Chapter 26
Chapter 27
Chapter 28
Chapter 29
Chapter 30
Chapter 31
Chapter 32
Chapter 33
Chapter 34
Chapter 35
Chapter 36
Chapter 37
Chapter 38
Chapter 39
Chapter 40
Chapter 41
Chapter 42
Chapter 43
Chapter 44
Chapter 45
Epilogue
The open windows
About the Author
THE
PATTERN MAKER
Nicholas Lim
Copyright © 2014 Nicholas Lim
The right of Nicholas Lim to be identified as the Author of the Work has been asserted by him in accordance with the Copyright, Designs and Patents Act 1988.
First published in Great Britain in 2014 by Richmond Press
A Richmond Press ebook
1.0.3.1
This ebook is copyright material and must not be copied, reproduced, transferred, distributed, leased, licensed or publicly performed or used in any way except as specifically permitted in writing by the publishers, as allowed under the terms and conditions under which it was purchased or as strictly permitted by applicable copyright law. Any unauthorized distribution or use of this text may be a direct infringement of the authors and publishers rights and those responsible may be liable in law accordingly
All characters in this publication are fictitious and any resemblance to real persons, living or dead, is purely coincidental.
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ISBN 9780992811914
Richmond Press
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For Ali
ACKNOWLEDGEMENTS
They say it takes a village to raise a child. I’ve learned the hard way that much the same is true of a book. I would like to thank my agent Judith Murray at Greene and Heaton for her repeated careful readings and insight. I would also like to thank Richard Skinner and the Faber group of 2012; without the stimulus and stamina provided by the fellow writers I found at the Academy this book might not have crossed the finishing line. Thank you also to Becky Swift at The Literary Consultancy; winning the Pen Factor competition was a very helpful stepping stone on the way to publication.
My editorial debts are legion but I would like to thank in particular Simon Rigge of Sheldrake Press for the opportunity he gave me to work with him years ago and for his editorial motto, “Prune and unify”, which still haunts me. And thank you to my first readers, Caroline and Felix Milns, Jill Paton Walsh, Carolyn Smith and Joel Moskowitz, who all gave me much useful advice as well as that invisible but most vital of supports, encouragement.
The cover of this edition is by the gifted photographer Patrick Dodds. The design is an example of his particular alchemy in combining the memorable with the simple.
Above all, I owe special thanks to my wife Ali without whose editing skill, support and love this book would not have been completed.
“Every epidemic begins with a first infection, a first death.”
Dr Christine Garrett, Senior Epidemiologist
West Sussex Primary Care Trust, July 2011
“Where the skull divides there lies the Gate of God.”
The Taittireeya Upanishad
Chapter 1
The morgue of the Brighton Royal is set apart from the main campus, screened off by a line of Holm oaks. The complex provides for all the needs of the hospital’s corpses, from cleaning, autopsy and viewing through to disposal. It was where Dr Christine Garrett felt most at home.
“You must go deep enough here and here.”
She made two swift cuts diagonally from each shoulder to the bottom of the sternum. She continued the last incision vertically down the abdomen to the pubic bone with a slight deviation to avoid the navel.
“You working late again tonight?” The intern Rafal Dudec waited for a glance from Garrett but her gaze remained focussed on the quick, definite movements of her hands.
“Yes.”
“I saw the Multiplex has started late screenings. I wondered–”
“You’ll notice the blood at the nose and mouth. A common result of passive congestion caused by a lowered head position.” Garrett’s knife parted yellow fat and whiter tissues from chest wall, rib cage and diaphragm. “Worth noting. The bleeding can cause diagnostic confusion. This woman was found yesterday floating face down off the end of Brighton Pier.”
Dudec nodded, quick bird-like nods. “Two drownings.” He glanced at the next table. “Looks like it’s going to be a busy bank holiday, Christine. Do you go to the cinema much?”
“No. I don’t have the time.”
“Well there’s nothing on right now. But next Saturday–”
Garrett shifted her grip on her knife and pointed with the tip. “Dudec, can we concentrate on this post?”
“Yes of course.”
“Remember, the chest is always opened before the abdomen.”
As Dr Garrett skinned the body's front, her sixteen-inch blade touched once or twice against the chain mail glove on her left hand. The chink of metal on metal was audible above the ever-present hum of air conditioning in the autopsy hall. The fans produced ten complete air changes per hour, but the smell of bleach, meat and opened bowels was constant.
“Isn’t it easier to use a scalpel?” Dudec said.
“It’s the usual choice. I prefer this knife. Either way, work with the edge not the point.”
“Right.”
“Up like so.” Garrett folded chest skin up over the face, like a winding sheet, and down the sides of the trunk.
“I’m off on holiday next week,” Dudec said.
“Good for you.”
“It’s a cruise. Only thing is I get seasick.”
“Sodium pentothal.”
“I heard that too. But my ex is coming. Not sure a truth drug would be a good idea. Any other suggestions?”
Using heavy curved scissors two-handed, like pruning shears, Garrett cut the ribs along both chest edges. Each bone gave way with an audible crack to leave a row of whitened ends.
“For seasickness? Sitting under a tree?”
Dudec blinked then grinned. “Okay.”
Garrett lifted off the detached chest plate and stopped.
From neck to groin the major internal organs were visible, packed inside the body cavity like belongings in a suitcase. The lungs were darkly blotched. The spleen was enlarged and sooty grey. But it was the liver – charcoal dark as if scorched, and grossly distended – that held Garrett still, as if at attention.
“My God!” Dudec lowered his head. “What is that?”
Fluorescent tubes in the ceiling ticked arrhy
thmically with heat and light.
“When you said diagnostic confusion–?”
Dudec was known for his smart mouth. As long as it matched his work that was fine by Garrett. She put down the chest plate and re-read the admittance notes.
“The cause of death wasn’t drowning was it?” Dudec pointed. “Every major organ has been infected by something or other.”
Garrett picked up the long prosector’s knife and began cutting again.
“I am freeing the organ block whole. It’s the quicker procedure.”
“Christine, do you have an idea what this is?”
“No. But I agree with your assessment of infection. The number of organs affected and the state of the liver and spleen – the vascular filtration units – suggests it’s blood related.”
Dudec looked excited. “This could be something new!”
“Rafal, when you hear hoof beats,” Garrett held up her knife like a warning finger, “Think horses before zebras.”
Dudec fiddled with a line of scalpels. He took a deep breath, like a little boy.
“I guess you see a lot of unusual cases, huh?”
“More than general practice. Epis move around different hospitals. Does path work interest you?”
“Um, not really. I’m more interested in going into the other end of things, maybe obstetrics.”
Garrett recognised the thought. Her specialty, epidemiology, dealt closely with patterns of health in populations, particularly causes of death. Not as common an interest as natal care. The other end of things. She divided the last attachments – pelvic ligaments, bladder and rectum – with one slash of the knife and carried the organ block to the dissection area.
“That liver looks scorched. Barbecued!” Dudec said. His voice wobbled with excitement. “I’ve never seen anything like it – have you?”
The mass of sooty meat, yellowed around the edges, began to overflow Garrett’s hand as she cut around the organ. She glanced up at Dudec, shook her head then stepped on a microphone foot-switch.
“Twenty-eight by twenty-four by twelve centimetres. Weight two thousand five hundred and fifty grams.”
“Er – that's enormous.” Dudec looked at Garrett as if she had asked him a question.
“Pronounced yellowing in the outer tissues characteristic of bile build-up.”
Garrett completed the initial organ dissection.
“Rafal, do you know how to prepare quick-freeze sections?”
He nodded.
“Liver first please.”
Garrett moved round to the head. The eyelids, where rigor had first appeared, had re-opened on relaxation of the small muscles. The eyes were the deepest royal blue. They reminded her of the lazuli robes of a Madonna that had hung in her room as a child, the colour of unquestioned faith. Around the iris the cornea showed yellow, signs of jaundice.
“Aren’t you going to do these sections with me?”
“We still haven’t established cause of death.”
Garrett made a single deep cut across the crown from ear to ear and pulled the front flap of skin forward and down over the cadaver's face, then selected a small handsaw and addressed the exposed skull. She glanced at a plaque set high on the facing wall, etched with black lettering. Hic locus est ubi mors gaudet succurrere vitae.
Garrett cut through the exposed skull bone around the equator of the cranium. She took care to make a small notch, not for medical reasons, but so she could restore the head shape in case relatives viewed the body. She stared for a full minute before dictating.
“Calvarium off. Cerebral hemispheres appear grossly swollen, with meningeal congestion. Colour abnormal. Black.”
Dudec looked up from his tissue sections. Garrett severed the spinal cord and tendon-like dural reflections between cerebellum and cerebrum and lifted out the brain. She peered into the head cavity. “Skull vault appears normal.” She carried the brain back over to the dissection area. Dudec came over to see.
“Jesus Christ.”
Garrett kicked the mike switch. “Cause of death: brainstem dysfunction. Tonsils of the cerebellum are softened and herniated.”
“Yeah! Crushed to a pulp. That must have been some pressure. This brain's imploded!”
Garrett stepped on the mike switch. “Rafal, please?”
“Sorry.”
She deepened the small incisions she had made in the base of the brain. “Pons, medulla oblongata and bulb are also all herniated. Cause: intense intracranial pressure.” She paused to adjust her face mask. Fingerprints showed up redly on the filter paper below her eyes.
“There is widespread thrombosis, haematomas, haemorrhaging.” Garrett pointed out to Dudec dense clusters of purple spots, like flea bites, all over the brain's surface. She began slicing sections through tissue and found penny-sized areas of paler tissue. “Localised cell death is visible in scattered infarctions throughout.”
“What the hell is this?” Dudec took a step back from the blood-smeared steel of the examination table.
“There is oxygen starvation, blood vessel ruptures, a clearly lethal increase in cranial pressure.”
“A black brain.”
Dudec looked at her. His eyes had a shifty, overwide look.
“You said blood-borne diseases. I can think of HIV, hepatitis B, hepatitis C, malaria. And also West Nile virus and the viral hemorrhagic fevers.” Dudec looked at Garrett, cheeks flushed. “Have I missed any?”
Garrett understood Dudec’s fear. The same emotion lapped at her too. But she knew how to deal with it, concentrating on near, necessary objectives and schooling herself with her science and reasoned facts. Normally, she would send the worker home. Fear was contagious as disease.
Garrett smiled. “Remember Rafal, horses not zebras.”
She maintained eye contact and raised her eyebrows. Dudec took a breath. He visibly steadied himself, roused himself to nod.
“That’s it. Now I need you to help me. Where are you with those sections?”
“Umm, the liver. I’ve frozen and sliced four–”
“Good. Let’s stain shall we?”
They worked in silence for a few minutes.
“You must think me a bit of a wuss.”
“No I don’t. You have an imagination. You need it for the job.”
“You don’t scare easily do you?”
Garrett placed a slide onto the lowered stage of a scope and added a drop of oil. “Right, let’s have a look at what we’re dealing with.”
She made fine focus and diaphragm adjustments. Her body became still.
“Well?”
Garrett nudged the stage slowly back and forth.
“See anything?”
Garrett stepped aside. She watched Dudec's hunched shoulders. She knew what he was studying. Scores of pale lilac forms, mostly round, some crescent-shaped, some distorted into ovoids or spheres like unopened shells. Within each pale shape further forms, coarse rice-like granules stained to reds, darker cinnamon, soot...
“I know what this is.” Dudec continued to peer down the binoculars. Garrett waited. “It’s malaria.” He looked up, triumphant. “Yes, must be.”
“I agree. The pathology matches cellular identification. The liver is the first target of attack for the malaria parasite, where it starts to breed. And I’d say, from the state of the brain, we’re looking at a cerebral malaria.”
“The colour is due to the malaria pigment.”
Garrett nodded. “Haemozoin. Did you see almost every single blood cell is colonised, deformed by the infection?”
Dudec looked back into the scope. “Yes. Yes, I see.” He straightened and glanced at her. “Have you worked with malaria cases before?”
“I was in India for two years with the WHO SEAN. I'm not an expert but I saw a lot of malaria infection there.”
“Like this?”
Garrett studied the sectioned brain on the steel counter. She thought of the slide images. “No. The pathology is extreme and the parasite blood colonis
ation – I’ve not heard of parasitemia approaching a hundred percent. We must be dealing with some new virulent strain. Most likely a holiday import.” She looked at Dudec. “Remember, it's only transmitted by the mosquito insect vector.”
He smiled his relief. Garrett returned to the opened body. She circled it twice, often bending down for a closer look, her movements careful and unhurried.
“What is it?”
“No bite marks.”
“Perhaps the infection was contracted early?”
“Perhaps,” Garrett conceded.
“The immune response could have subsided before death?”
Garrett nodded, still staring at the body.
“Or this was a relapse after long intermission. Malaria can be chronic.”
“Maybe.” Garrett sighed. “Look why don't you start typing up the notification for CDSC while I clear up?”
“Ok. You want to grab a coffee first? We could do with a break I think.”
“Thanks Rafal, but no, I want to finish up here.” Garrett glanced at the table with the remaining post under a blue plastic sheet.
“What about that one?”
“Tomorrow.”
After Dudec had left, Garrett worked in silence. She closed the autopsied corpse and sluiced down the floor. She cleaned and sorted instruments ready for the next day; when she had finished, the stainless steel tools lined up in neat ranks in their racks.
On her way out, as she passed the last body waiting examination, she heard what sounded like a sigh, almost a protest. She came from a Dissenting people – who would not cross the road at ladders, consult tea leaves or shy from black cats – and she dismissed her gut reaction, reminding herself of the normal action of bacterial decomposition in the digestive tract after death.
It had been a long day. Tomorrow was fine. No need to rush.
***
The hospital chapel, a brick fragment of the original Victorian hospice, was attached to the morgue. Garrett paused at the door to make sure there was no one inside. She could hear nothing. A draft of cool escaping air smelled of candle wax, incense and dust.