The Sinner: A Rizzoli & Isles Novel

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 peri-apical series to highlight the maxillary landmarks.”
    Cawley reached inside and pulled out more X rays. She clipped up a peri-apical 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.”

T HIRTEEN
     
    T HE 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