Heather Miller was a general practitioner with an office in the lower floor of her house. She was about forty-five, short and wide, with chestnut hair cut in a bob. Her desk was made out of a thick glass sheet supported by marble blocks. When Sandra Philo came in, Miller waved a hand, indicating she should sit in a green leather chair facing the desk. “As I said on the phone, Detective, I’m severely constrained in what I can say because of physician-patient confidentiality.”
Sandra nodded. It was the usual dance, the establishing of turf. “I understand, Doctor. The patient I wish to discuss is Rod Churchill.”
Miller waited.
“I don’t know if you’ve heard yet, but Mr. Churchill died last week.”
The doctor’s jaw dropped open. “I hadn’t heard.”
“I’m sorry to be the bearer of bad news,” said Sandra. “He was found dead in his dining room. The medical examiner said it had likely been an aneurysm. I visited his house and found that you’d been treating him with Nardil, which, according to the label, means he had to watch what he ate. And yet he’d been eating take-out food before he died.”
“Damn. Damn.” She spread her arms. “I told him to be careful about what he ate, because of the phenelzine.”
“Phenelzine?”
“Nardil is a brand name of phenelzine, Detective. It’s an antidepressant.”
Sandra’s eyebrows went up. Bunny Churchill had thought both her husband’s prescriptions were for his heart condition. “An antidepressant?”
“Yes,” said Miller. “But it’s also a monoamine oxi-dase inhibitor.”
“Which means?”
“Well, the bottom line is if you’re taking phenelzine,. you have to avoid foods high in tyramine. Otherwise your blood pressure will go through the roof — a hypertensive crisis. See, when you’re taking phenelzine, tyramine builds up; it’s not metabolized. That causes vasoconstriction — a pressor effect.”
“Which means?” said Sandra again. She just loved talking to doctors.
“Well, that kind of thing could conceivably kill even a healthy young person. For someone like Rod, who had a history of cardiovascular problems, it could very likely be fatal — causing a massive stroke, a heart attack, a neurological event, or, as your medical examiner suggested, a burst aneurysm. I assume he ate the wrong thing. But I warned him about that.”
Sandra tilted her head. Malpractice was always a possibility. “Did you?”
“Yes, of course.” Miller’s eyes narrowed. “That’s not the sort of mistake I make, Detective. In fact — ” She pushed a button on her desk intercom. “David, bring in the file on Mr. Churchill, please.” Miller looked at Sandra. “Whenever a drug involves substantial risks, my insurance company makes me get the patient’s signature on an information sheet. The sheets for each drug come in duplicate snap-sets. The patient signs them, I keep the duplicate, and he or she takes away the original — with all the warnings spelled out in plain English. So — ah.” The office door opened and a young man walked in holding a file folder. He handed it to Miller, then left. She opened the thin file, pulled out a yellow sheet, and passed it to Sandra.
Sandra glanced at it, then handed it back. “Why use phenelzine if it has so many risks associated with it?”
“These days we mostly use reversible MAO inhibitors, but Rod didn’t respond to them. Phenelzine used to be the gold standard in its class, and by checking MedBase, I found that one of his relatives had been successfully treated for the same sort of depression with it, so it seemed worth a try.”
“And what exactly are the risks? Suppose he ate the wrong food? What would happen?”
“He would start by having occipital headaches and retro-orbital pain.” The doctor raised a hand. “Excuse me — that’s headaches at the back of the head and pain behind the eye sockets. He’d also have had palpitations, flushing, nausea, and sweating. Then, if he didn’t get immediate treatment, intracerebral bleeding, a stroke, a burst aneurysm, or whatever, to finish him off.”
“It doesn’t sound like a pleasant way to go,” said Sandra.
“No,” said Miller, shaking her head sadly. “If he’d gotten to a hospital, five milligrams of phentolamine would have saved him. But if he’d been alone, he could easily have blacked out.”
“Had Churchill been your patient long?”
Miller frowned. “About a year. See, Rod was in his sixties. As often happens, his original doctor had been older than him, and he died last year. Rod finally got around to finding a new doctor because he needed his Cardizone prescription renewed.”
“But you said you were treating him for depression. He hadn’t come to see you specifically for that?”
“No — but I recognized the signs. He said he’d had insomnia for years and when we got to talking about things, it seemed clear that he was depressed.”
“What was he sad about?”
“Clinical depression is a lot more than just being sad, Detective. It’s an illness. The patient is physically and psychologically unable to concentrate and he or she feels dejection and hopelessness.”
“And you treated his depression with drugs?”
Miller sighed, picking up the implied criticism in Sandra’s tone. “We’re not stringing these people out, Detective; we’re trying to get their body chemistry back to what it should be. When it works, the patient describes the treatment as being like a curtain drawing away from a window and letting the sun in for the first time in years.” Miller paused, as if considering whether to go on. “In fact, I give Rod a lot of credit. He’d probably been suffering from depression for decades — possibly since he was a teenager. His old doctor had simply failed to recognize the signs. Lots of older people are afraid of having their depression treated, but not Rod. He wanted to be helped.”
“Why are they afraid?” asked Sandra, genuinely curious.
Miller spread her arms. “Think about it, Detective. Suppose I told you that for most of your life your ability to function had been severely impaired. Now, for a young person like yourself, you’d probably want that fixed — after all, you’ve got decades ahead of you. But older people very often refuse to believe they’ve been suffering from clinical depression. The regret would be too much to bear — the realization that their lives, which are now almost over, could have been so much better and happier. They prefer to shut out that possibility.”
“But not Churchill?”
“No, not him. He was a Phys. Ed. teacher after all — he taught high-school health classes. He accepted the idea and was willing to try the treatments. We were both upset when the reversible inhibitors didn’t work for him, but he was game for trying phenelzine — and he knew how important it was to avoid the wrong foods.”
“Which are?”
“Well, ripe cheese for one. It’s full of tyramine as a breakdown product of the amino acid tyrosine. He also couldn’t eat smoked, pickled, or cured meats, fishes, or caviar.”
“Surely he’d notice if he was eating any of those things.”
“Well, yes. But you also get tyramine in yeast extract, brewer’s yeast, and meat extracts such as Marmite or Oxo. It’s also in hydrolyzed protein extracts such as those commonly used as a base for soups, gravies, and sauces.”
“Did you say gravies?”
“Yes — he should have avoided them.”
Sandra fished in her pocket for the small, stained slip of newsprint — the receipt from Food Food for Rod Churchill’s last supper. She handed it across the glass desktop to Dr. Miller. “This is what he ate the night he died.”
Miller read it, then shook her head. “No,” she said. “We talked about Food Food the last time he was in. He’d told me he always ordered their low-calorie gravy — said he’d checked and that it was free of anything he was supposed to avoid.”