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Quirke, a pathologist in 1950s Dublin, is perturbed when his strait-laced adoptive brother Malachy, an obstetrician, appears to be tampering with evidence relating to the recently deceased Christine Falls. Officially she died of an embolism but Malachy admits that she died giving birth to a still-born child and evidence was changed to spare her reputation. Soon afterwards Dolly Moran, a friend of Christine who told Quirke she has information about the baby's father is murdered and a child brought from Ireland to Boston, Massachusetts, is adopted by Claire and Andy Stafford. Quirke discovers that Dolly was part of a chain who took illegitimate children to America and is savagely beaten up for his pains. At the request of Malachy's wife Sarah Quirke takes her wayward daughter Phoebe to Boston to stay with her grandfather, dying Irish industrialist Josh Crawford and here he learns that Josh is instrumental in bringing illegitimate Irish babies to America. When Josh dies Sarah, Malachy and Quirke's adoptive father Garret, a judge, attend the funeral, where Quirke finally uncovers the truth about Christine's baby as well as having to admit to Phoebe another family secret.

Mal is still angry with Quirke for revealing Phoebe's true paternity and blames him for her quitting medical school to work in a hat shop. Here she meets louche Leslie White, manager of the Silver Swan beauty salon who is having an affair with Deirdre, wife of pharmaceutical rep Billy Hunt, a former student of Quirke. Deirdre is addicted to tranquillizers in return for which she agrees to pose for nude photos which White uses to blackmail her. At the same time Quirke deals with the suicide of housewife Geraldine Millican, who like Deirdre posed nude to get her tablets. After Quirke has failed to warn Phoebe about White he persuades Garret to take drastic action, revealing White's true nature to Phoebe. Several deaths follow, which Quirke is able to help solve but he is unprepared for sad news about Sarah, with whom he had been having an affair.

Phoebe is worried that she has not seen her friend April Latimer for some weeks and persuades Quirke, still coming to terms with Sarah's death, to help find her. April's brother Oscar, a doctor, tells them that April's wild behaviour has caused her estrangement from the family for some years and indeed neither her icy widowed mother Celia or her uncle Bill, a government minister, seem especially concerned. Quirke learns that April had a visit from another doctor Patrick Ojukwu, whom, it was assumed, was one of the many men in her life but blood stains at her flat lead to the revelation that Patrick was carrying out an abortion and that the family would have been disgraced if the news were made public.