“In pregnancy the skin of the abdomen is stretched beyond the point of normal elasticity,” she offered. “So there are stress lines that appear purple at first, and eventually fade to white. This lady’s abdomen showed stretch marks of two distinct shades, some almost white, others still pink.” She waited, and got nods from both of them before she went on.
“In addition to stretch marks, there is scarring to the perineum. Wait,” she said, in response to Jack’s raised brow. “I’ll explain. If the birth is difficult—say, the child is large and the mother is weak after a long labor—an attending doctor will often make an incision from the vagina toward the anus to increase the circumference of the birth canal. The idea is to avoid tearing, which can be difficult to stitch. Closing an incision is easier than stitching a tear; at least that’s how the reasoning goes.”
Anna could almost hear Oscar blushing, and Jack, she thought, wasn’t much better, despite the frank discussions they had been having recently. She studied the report for a long minute. When she thought they had had enough time to compose themselves, she went on.
“The surgical procedure is called an episiotomy. It’s done too often, in my opinion, usually by doctors who are in a hurry. In Mrs. Liljestr?m’s case the person who delivered her made an unusually large incision that didn’t heal well. She had granulomas along the suture line, nodules of scar tissue that indicate that her sutures weren’t removed very carefully. Even tiny bits of suture can cause irritation and infection, and the body reacts by isolating the fragment and walling it off, so to speak.”
Oscar cleared his throat. “That’s in the past, though.”
“Yes,” Anna said. “But a thorough autopsy doesn’t leave anything out.”
Jack said, “The granulomas aren’t relevant to the cause of death?”
Anna considered for a moment. “That would be conjecture on my part.”
“Go on and conject,” said Oscar. “We won’t tattle on you.”
She gave him a half smile. “The scarring indicates that she had at least one very difficult birth. Some women have such bad experiences that they simply can’t face the prospect again. This woman had an abortion, that’s undeniable, but there’s no way to know if she was driven by fear of childbirth. But she had a hard time of it, that’s a certainty.”
“The operation itself,” Oscar said. “Anything you find unusual?”
“It does happen sometimes, especially with less experienced practitioners. Too much pressure with the instrument in exactly the wrong spot, and it sliced through the wall of the uterus and severed the uterine artery. The blood loss would be catastrophic, and very fast.”
“Like cutting a throat?” Jack asked.
“Something like that,” Anna said.
Oscar said, “So no similarities to Janine Campbell’s case.”
“The outcome was the same, of course. But in Mrs. Campbell’s case no major blood vessels were damaged, which is why she had such a long and painful death. She bled, yes, but it was the infection that killed her. This second case is different. Mrs. Liljestr?m suffered very little beyond the initial pain of dilating the cervix to introduce the instrument. It was, relatively speaking, a merciful death. Or at least, fairly quick.”
“She arrived at Bellevue in a cab,” Oscar reminded her. “Still alive, but just barely.”
“That is odd. And another thing—” She paused, and forged ahead. “Dr. Lambert notes that she was fully clothed when she died, and she was very tightly laced.”
“You’re wondering why she wasn’t undressed for the operation,” Jack said. “And if she did undress, who got her dressed afterward and tightened her stays.”
“Yes,” Anna said. “She couldn’t have done that on her own. I’m not sure how any of this could have happened.”
“That’s our job,” said Oscar. “Figuring out the how and why of it.”
? ? ?
LATER, ALONE IN their room, Anna was thoughtful. She said, “The most unusual thing about Mrs. Liljestr?m is her wealth. Women with money can get excellent care when they want an abortion without looking very far at all. But whoever she went to had very poor skills.”
Jack thought, Or very good ones. He said, “There are odder deaths every day in this city, and a good number of them go unsolved.”
She raised a brow, wanting the story but not sure if she could ask for it.
“A few years ago on a January morning we found a man of about seventy dressed in the uniform of a Confederate officer sitting upright on a bench in Union Square Park.”
He could see her trying to imagine it. “Did he freeze to death?”
Jack shook his head. “Strangled. We never did identify him, though notices were put in papers all over the south. Never had a single viable suspect.”
“But this shouldn’t be one of those cases. When rich women like Mrs. Liljestr?m need this particular kind of help, they talk to other women like themselves. I imagine she didn’t want to take the chance of being recognized in Buffalo, and so she came here prepared to pay for anonymity and excellent care. Mrs. Campbell didn’t have the same kind of resources.”
“You don’t know what kind of resources she had,” Jack pointed out.