Chapter 4

It was the morning of September 10th, when the morning examinations had begun and he was just thinking of taking a break that Toshio received the call from the National Hospital in the town of Mizobe.

"Doctor, the phone. It is from the National Hospital's Dr. Taniguchi."

Ritsuko turned the phone over to Toshio who excused himself from his patient to return to the waiting room. There, he took the call.

Taniguchi from the national hospital was an older physician than Toshio. His upperclassman by seven years from the same university, of course they knew each other from the university itself but being the connection between a senior and a junior afforded him certain accommodations. That said, Taniguchi himself wasn't born in Mizobe, nor did he live in the vicinity of Mizobe. Taniguchi came to the national hospital twice a week as a side job to lecturing at the university. He came from the city on an express train for two days a week, then went back.

The national hospital was a hospital large enough to rival the mutual aide hospital of the JA but the truth was that size was all there was to it. The doctors employed there full time were young with no career. They came rushing in from their bases to make a career there in order to then return to their home towns and serve as private physicians. Those who didn't were old fogeys who lost their place to call home to go back to. There were doctors with experience who, while having established suitable social standing in the city, would come in so many times a week for consultation.

"I've switched lines." Toshio took the receiver.

"Ah, Toshio-kun. This is about the patient you had turned over to us the other day, yes?"

Because of the relations between juniors and their upperclassmen, Toshio often relied on Taniguchi in order to turn over obstreperous treatment cases---that is, patients who would require hospitalization for any long period--to the national hospital. If they required surgery, they went there, if they required brain surgery, they'd be there, there were plenty of routes. Toshio himself didn't turn much of a profit from this but in exchange he received information. There was also the benefit of being able to ask about their progression easily.

"Do you mean Yasumori Mikiyasu?"

"Mm, yes. About him, this morning he died of renal failure at 5:16 AM."

Is that so, Toshio murmured. When overseeing him as he was taken away by ambulance, Toshio had resolved within himself that that may have been the last time he saw his childhood friend.

"What was the progression like?"

"When he was carried in, he had quite severe anemia, as you know. I wasn't present so I don't know, but. His creatinine levels were high so we were vigilant regarding renal failure but MODS developed into DIC, resulting in MOF. Do you need detailed progression notes?"

[TL/N: MODS - Multiple Organ Dysfunction Syndrome

, previously known as MOF for Multiple Organ Failure. MODS was the only one not defined explicitly in the chapter. Commonly the result of sepsis which leads to reduces in blood flow to the relevant organ systems. In typical MODS, this is because of disseminated intravascular coagulation (DIC, mentioned in chapter) syndrome, or abnormal blood clotting which leads to organ systems breaking down due to not getting enough blood to function]

"It may put you through great pains, but by all means, please. Quickly, if you could."

"A thorough student aren't you, as always."

Toshio smiled bitterly. "Mikiyasu is a childhood friend. ---It is a small village."

Ah, said Taniguchi, his voice awkward. "That's, I'm very sorry to hear that. It was a bit of a strange progression, wasn't it? At least from looking at his medical records, I wouldn't think he'd had such severe renal impairment, but. If only I could have seen him when he first came in, but it wasn't my consultation day."

"It is a shame. ---Was it aplastic anemia, or was there a white blood cell disorder?"

"There wasn't, actually."

"None? You are sure?"

"Mm. You said as much. For the record, we ran thorough tests here ourselves, though. It seems it was not aplastic anemia. There was nothing unusual with his bone marrow. He had high neutrophil counts but his white blood cell count and hematopoietic figures weren't abnormal."

"Is that so," Toshio answered while thinking 'I knew it.'

"Will a fax do?"

"It will do nicely."

Toshio conveyed his gratitude to Taniguchi and hung up the phone.

(Toshio-san)

Mikiyasu's voice lingering in his ears sounded naive---he guiltily strove to forget that voice that had been relying on him. There was no use in holding it in his heart forever. This wasn't so special of a tragedy, not compared to what it meant for the village as a whole.

Before notice of Mikiyasu's death came in, he had just received notification from Ishida that a man in Shimo-Sotoba had died. yesterday Seishin had reported that an old woman in Naka-Sotoba died. The day before yesterday Ishida, again, conveyed that an office worker living in Mizuguchi died. At this rate, the situation was quickly becoming more urgent.

(It's contagious.)

There was no proof but he was already certain. The first infected person became the contagion and a secondary infection occurred. Those patients who were the victims of the secondary infection were many. And from those secondary infection patients as a source of contamination came third wave infections. ---This indicated how the situation, the infection was expanding.

(The time span is short...)

Regardless of the fact that it appeared the incubation period was a week to two weeks, the time span in which the infection was expanding was far too short for that. As expected, maybe it wasn't something that spread from person to person. With fleas and ticks as the carriers, it could have broken out in a day or two. But, living in the mountains, it would be difficult to find less air tight houses than most of those in the village. How on earth were they to exterminate the carrier animals?

Toshio felt something akin to a faint chill. Just maybe, this could have been a calamity beyond what Toshio had first imagined as a "worst case scenario."

"Mikiyasu-san died, you say?" At Ritsuko's words, Yasuyo's eyes widened.

"Yes. Just now there was a call from the National Hospital."

Really, said Yasuyo, her hands washing her teacup coming to a stop as she gazed into the kitchen sink.

The kitchen was a remnant of the times when they took in-patients. They used to prepare meals here for in-patients, and in the dinning room near by staff could also eat. That dinning room was now the break room. In one enclosure was a break room, a washroom for kitchen staff that they no longer had, but its sofa had become a space for napping.

From that point on the kitchen may have gone unused but even now it was maintained as if it were used, and Ritsuko at times used it to heat up lunch or even to do light cooking. There was a separate kitchenette for preparing tea but when taking breaks it was more convenient to use the kitchen. And the kitchenette was narrow, so when it came time to clean up afterwards it was more common for everyone to make use of the kitchen at once.

Yasuyo was caught in her thoughts, her hands stopping, but her face suddenly lifted as if her breath were cut short, wiping at her hands.

"RIcchan, sorry, but I'll leave this to you. I'm going to talk to the doctor."

"Yasuyo-san."

"It'll just be a bit, as expected we can't not ask the doctor about the status of thing. It looks like the part timers are uneasy about it too, and all."

Her intent stated, Yasuyo stepped out of the kitchen. It wasn't long after that she returned.

"Ricchan, do you have plans this afternoon?"

"No."

"Then, when work is finished, could you stay behind, I wonder? We're holding a little meeting. For lunch it sounds like the doctor will prepare lunches for it."

Yes ma'am, Ritsuko answered while thinking 'at last.' Toshio would have an explanation. She had a feeling she wanted to hear it and didn't want to hear it. If she heard it, it would be confirmed, she felt. Ritsuko and the others imagining something and Toshio as a doctor declaring it were different matters entirely.

Nervously finishing the cleaning, she returned to work. Each other staff member she saw seemed to have the same nervousness but nobody said a word. Caught up in the strange flowing feel of tension, even as noon came the flow of patients didn't stop. Lately, it had become customary for their lunch hour to be pushed back. There were many patients. It didn't seem like there were many who seemed especially sick. They had the impression that patients were coming in with symptoms that they wouldn't usually come into the hospital over. Those patients in particular would talk with Toshio for a long time, dragging out medical examination hours.

(We're in suspense...)

That's what Ritsuko thought. The patients--the villagers were, whether conscious of the increasing number of deaths or not, vaguely awayer that something was strange, that their health and very lives could suffer unusually easily. That was likely a disease spreading throughout the villagers. And that was surely from now on going to compound beyond the level it was at even now.

Taking lunch in shifts, Ritsuko handled the patients. The last patient's examination ended past two o'clock. Finishing up cleaning afterwards, she went towards the break room, where all staff members were already assembled.

"Ricchan's the last?" Toshio smiled before a stack of documents piled on the table. "Close the door and have a seat."

His tone was the same as always. Taking some relief in that, Ritsuko closed the door and sat in the empty seat. In the break room was the cool air of the air conditioner, and in that air the more chilling draft of their nervousness.

"You might already know this but today the contractor's Mikiyasu died," Toshio began his talk, looking towards Mutou and Towada. "This might be a hard conversation for Mutou-san and you to follow but if there's anything unclear, just ask. And be patient."

Mutou and Towada nodded.

"With Mikiyasu dead, that makes the death toll since August nineteen people."

That hit like a bomb. Ritsuko's back muscled tensed. The voices saying 'that many' were multiple, and Ritsuko may have unconsciously gave voice to such herself.

"There have been that many, actually. Amongst them are ones who didn't have anything to do with us, who collapsed in Mizobe and were taken to the hospital there, or who were taken off to there. Anyways, the government office has been sending in death certificates, and counting them up, Mikiyasu is the nineteenth. --It's an abnormal situation."

Ritsuko lightly swallowed her breath.

"And Mikiyasu was, following Nao-san and Susumu-kun, the third death at the contractors. It's possible everyone here's been faintly aware of it but there's the possibility that it's an epidemic."

"Doctor, are you sure?" Mutou leaned forward.

"I'm sure people are dead. And it's clear there're excessive deaths, and an increasing trend at that. I think that we can be pretty certain in thinking that it's an epidemic."

Saying that, Toshio roughly explained how things had progressed. Concretely, he gave the names of the dead and their causes of death.

"By the way, the result of the blood tests on the contractor's Nao-san and Mikiyasu were both negative for any epidemics. Based on the test results, the two of them were indeed not infected with any known epidemic. I requested a culture test too but I don't have all of those results yet. Culture tests take time. I think that it'll be a little longer until the cultures come back but if nothing else based on what we know at this time, the two of them weren't carrying any germs that would cause them to suddenly lose their lives. Murasako Mieko-san was the same. The results that came back from the police were completely clean."

Uhm, Towada spoke up. "Even though the results haven't come in, can you declare that it isn't an epidemic? I thought that the doctor had just said that it was an epidemic, but."

"Mm, it comes down to this. ---The cause of an epidemic is a pathogenic microbe. When those microbes ravage a body, it's called an infection. All of them are indeed

contagious

, epi for spread demic for among the people, but among those infections, the one that inflict grave damages to the human body, the ones that have such an effect that society can't afford to disregard them are called epidemics. Amongst all types of infections are ones we're especially vigilant against called epidemics. ---Are you following this so far?"

"Ah.... yes."

"So an epidemic is strictly those infections that have been labeled "epidemics." Right now, the thing that's spreading through the village doesn't correspond to any of those predefined epidemics. Based on the symptoms as well as the test results, it's cleared from being any of them. So it's not an epidemic but based on the observations of the increasing numbers of patients, it's clearly contagious. And the results are grave, and the number of patients is high. It's not an existing epidemic but it's clearly an infection disastrous to society. As far as its ability to influence people and society, I think it'd be appropriate to call it an epidemic."

"Ah, I understand."

Toshio nodded,

"It's not an existing epidemic, and the possibility, however small, that it's not an infection, still remains. It's possible to think that it's some kind of poison or an allergic reaction to something. Anyway, it'd be accurate to say we still don't know what's happening. We don't know the cause of the disease, or how it spreads."

Yasuyo raised her hand.

"Is there the possibility that it's a new type of epidemic?"

"The possibility that it's a new kind, of course, exists."

"What will we do about this from now on?" Mutou said, sounding lost.

"If only we know, huh? At any rate, until we know the cause of the chain of deaths, our hands and feet are tied. Not only can't we treat or prevent it, we can't ask the administration for assistance."

"There's no way to have the administration investigate it?"

"I plan to do that. That said, I have to put together the data and the related materials. I've got to do that and make sure to have the administration see the need to investigate it. All of this, the Health Department's Ishida-san is currently investigating." Toshio said, with a bitter smile. "If it's an existing epidemic or a rogue strain, it'll be fast work. We haven't gotten any results of that nature yet, so we have to get together the materials with more explanatory power. Regardless of everything, we don't have any solid proof that it's contagious. It'd be best to think of this as something that's going to take time."

"The administration is slow to do anything at times like this, aren't they? If you don't pester them with quite a bit of proof, then...." Mutou breathed a deep sigh. Everyone present sighed as well with agreement.

"What we know right now is that it seems to start with anemia. At least, Shimizu Megumi-chan, the Yasumori's Nao-san, and Mikiyasu, that's three people, didn't have anything you could point to as wrong with them besides anemia. Anemeia occurs, so their complexion is poor, they feel washed out and have no appetite. The people around them think the summer heat is getting to them, or that it's a cold, and it's easy to overlook."

"What is the cause of the anemia?" Kiyomi asked, causing Toshio to shake his head.

"That I don't know. Looking at the test results, it's normocytic normochromic anemia. At least we know it isn't iron deficiency anemia or pernicious anemia. It doesn't seem like it's a blood formation disorder. The National Hospital tested Mikiyasu but they said to me that he probably didn't have aplastic anemia or leukemia. Looking at the rest results, you would think it was anemia coming from external bleeding or hemolysis but there're no signs of internal bleeding that could be the cause of the anemia."

Shimoyama nodded. "We used a CT to search here and there for that. ---That's right, there is no internal bleeding. At least, there wasn't for Yasumori-san's wife."

Toshio nodded.

"In cases where it's a small continuous bleed, X-rays or ultrasonic rays may miss the bleeding spot but, in this case, I don't think that's it. If nothing else, since it suddenly gets so much worse and all. Thinking of the situation up until now, it call comes to an end within a few days. The progression is about that fast."

"Then, what about hemolysis?" Yasuyo asked.

"Going by the process of elimination, the only thing left is hemolysis, but. In cases of hemolysis, bilirubin and LDH levels should be higher. Yet in the initial stages, that doesn't show up. Coombs tests come up negative too, so if nothing else it's certain not to be hemolysis from an autoimmune disease."

"So there's no hemolysis that doesn't raise that---whatever it was called?" Mutou said.

"It's not that there isn't. There's intravascular hemolysis and extravascular hemolysis but in the case of intervascular hemolysis, serum bilirubin levels and LHD levels don't raise. In those cases, hemoglobin would be in the blood plasma or there would be hemoglobinuria but that wasn't the case in Nao-san or Mikiyasu. On the other hand, in the case of extravascular hemolysis, it's common for biliruin and LDH levels to rise but it seems that isn't certain to hapen."

Mutou groaned, sounding terribly confused.

"Anyway, I think that the odds of hemolysis are high. And not something congenital, it's acquired. It's not something that effects immunity, but that raises the sensitivity of the complement system, or possibly something that causes red blood cells to be crushed, or it may be some drug or poison."

"Poison, you say?" Yasuyo said, Toshio nodding.

"Spider or snake venom, or even bee venom can cause hemolysis it seems. If it's a snake or a bee, the patient or their families would probably remember being bitten or stabbed but there's the possibility it was a spider or another insect of some sort whose poison is causing the hemolysis. --Then there's drugs. Sulfa drugs or salicytic acid, or lead or arsenic could also cause hemolysis. In that case, the soil, the water, or possibly the food could be contaminated but based on the patients' behavior, this is a very low possibility, I think."

"What about existing epidemics?"

"It's modeled like malaria but it's probably not malaria. There's no high fever characteristic of malaria. We could think of it as a rogue strain of it but I'd think that tests for malaria would pick up on a rogue strain of it, too."

"The patients who die are mostly doing so in the middle of the night, aren't they. The notifications come in first thing in the morning, don't they?" Kiyomi said. "It isn't PNH?"

"I think we could suspect that too."

PNH, Mutou mumbled, to which Yasuyo answered.

"Paroxysmal Nocturnal Hemoglobinuria, possibly. But, it's written in the books that PNH progresses slowly. Could it be a more vicious type of that, I wonder?"

Kiyomi nodded. "With PNH, pancytopenia occurs. That said, Nao-san had lowered coutns of all blood cell types didn't she? Because of that, she became more prone to infection, and with a tendency to hemorrhage, a blood clot could form. Nao-san had heart failure, didn't she? A pulmonary edema came from that."

"I wonder if it was heart failure from a blood clot?"

"That is a possibility, isn't it? Also, it was written in the books that it could lead to death by renal failure too, but. Gotouda Fuki-san was renal failure, wasn't she!"

Toshio smiled wryly. "You've really done your homework. I'm in awe."

Yasuyo and Kiyomi's voices raised in a laugh. They both pointed their fingers at each other, saying they didn't feel like doing it but the other kept pushing it, blaming it on each other. Toshio laughed too,

"The contractor's Mikiyasu died of renal failure too. When I first had him taken away to the hospital, his BUN levels were elevated. His creatinine levels were within normal ranges so at first the doctors thought that he was dehydrated due to the heat but later he had bloody urine and obvious signs of renal failure. The doctors tried to treat that but in the end renal failure lead to DIC occuring and things suddenly turned for the worst and he died."

What is DIC Towada asked Satoko. As Satoko seemed uninterested in answering, Kiyomi answered.

"Disseminated intravascular coagulation syndrome. In short, abnormalities in how the blood coagulates."

"Our nurses are efficient," Toshio laughed. "But, while the rest results show the cause of death was uremia, it wasn't just his kidneys, his lungs and liver were malfunctioning too. At first it was respiratory failure that was occurring. At the end he contracted pneumonia, and his liver functioning fell drastically. He died of uremia so on the surface it looks like just renal failure but if he died because he couldn't breathe, it would have probably said lung failure."

"Multiple organ failure---MOF, then. Or these days, they call it, what, MODS?"

Kiyomi asked, to which Yasuyo nodded.

"At any rate, it looks like the whole body just starts falling apart. The first characteristic symptom is anemia, then it worsens steadily into MOF. The problem becomes how to defer it." Yasuyo spoke, looking to Toshio. "If we don't do something within three days, it becomes unmanageable doesn't it? Without the time to investigate what's happening, there's no time to search for a treatment. ....This is very serious, this matter."

"What's the route of infection?" Kiyomi asked, to which Toshio shook his head.

"We don't really know. I had Seishin look into the connections between the patients but no matter how you think about it, there are patients without any direct contact."

"It's hard to think of it as a direct infection, in other words. At Shimizu-san's place, the only one to be hit was Megumi-chan, and all. At the Maruyasu Sawmill, it was just Giichi-san, wasn't it? At Maruyasu, Giichi-san was bed ridden, with the family even tending to his bedpans, so it would seem like it would transfer directly to the family, and yet."

"That goes for us too, doesn't it?" said Yasuyo, teasingly. "We've gone out as nurses amongst them after all. Like this, we're lined up at the goose's neck for the patients, so it can't be a direct infection can it? It's likely not a droplet infection either. Though it seems like it would spread by blood. We might use gloves, but I can't imagine the family would."

"If that were the case, the Maruyasu family would obviously be hit a lot harder, wouldn't it! Since that's not the case, doesn't that mean that it doesn't spread through the blood?"

"Then, an intermediate carrier animal? Why, that really will be a hassle!"

"If it's an intermediary animal, wouldn't there be more of a concentration of where the victims are? It feels like they've come from all over the village, doesn't it? Could it be a matter of the ratio of outbreaks? Even if you're infected, the rate of outbreak could be low, don't you suppose? Whether it spreads to the family or doesn't spread to the family;could it be a matter of constitution?"

"That's true..."

"Family it spreads to and family it doesn't, huh..." Toshio said to himself. "Well, even if we talk about it here, nothing's going to happen. Anyway, we need to gather more medical cases, for now."

"That we do."

"Right now I'm suspecting carrier animals. That seems to be the highest likelihood. It's just, looking at the most recent patients, patients coming from the same concentrated families are rare. The Gotouda-san's place and the contractor's cases are the exceptions. It seems like the infection rate, or possibly the outbreak rate isn't too high, you could probably say. That said, don't get too comfortable. Anyway, be sure to wash your hands, wear gloves, and be thorough with things like that."

"And to also be careful with handling medical waste, too." Kiyomi said, to which

Toshio nodded.

"I think everyone else is worried too but if we take care I think there's the chance we can protect against it. We have to protect ourselves too, and to make sure we don't become a source of contamination, I'd like everyone to take care."

At Toshio's words, everyone nodded.

"And also, don't spread this out. We don't know a single thing for sure yet, after all. There's no point in inciting a useless panic. Ishida-san and me are taking the necessary measures to keep it quiet."

To this, too, everyone nodded.