You can frighten people with death or an idea of their own mortality, or it can actually give them vigour.
Damien Hirst
A DETECTIVE INSPECTOR once told me that the key thing to remember at a crime scene was to keep your hands in your pockets; the temptation to reach out and touch a murder victim, or a potential murder weapon, could be overwhelming. He had little faith in forensic pathologists. ‘I was at a scene where a dead man lay slumped over a desk,’ he told me. ‘There was a narrow entry wound on the back of his head, and a hole in the victim’s forehead. A Bakelite phone on the desk was shattered into pieces – he had obviously been shot. The pathologist arrived: “Hmm,” he said. “Looks like we’re searching for a stiletto, or maybe a knife.”’
Once he was called to a high-rise block of flats. A body had been found in an advanced state of decomposition. ‘It was the strangest thing I’ve ever seen,’ he told me. ‘I had a witness saying she was alive only the day before, but the witness must have been wrong. There she was, turning into liquid.’
He had retired early, and I asked whether having dealt with so many murders had made him pessimistic about life. ‘Not pessimistic,’ he said, ‘but more philosophical. Enjoy it while it lasts.’
AFTER OUR BRIEF ENCOUNTERS in the clinic, my patients go out into the world, and it may be months or years until I see them again. Occasionally, I hear later from the hospital or the police that they’ve died. That death is usually in some way expected, or could at least have been anticipated. When death comes as a surprise, or is in some way suspicious, the body of the deceased goes for an autopsy, or post-mortem.
Recently, on the phone with a pathologist about a post-mortem report that she had prepared on one of my patients, I realised how rarely I had cause to speak to her or her colleagues. ‘So much of my practice is guesswork,’ I said to her, ‘trying to figure out what’s going on beneath my patients’ skin. I envy you being able to take a look inside and figure out what’s happening once and for all.’ ‘That’s a misconception,’ the pathologist, Charlotte Crichton, replied. ‘We don’t have all the answers either.’ She invited me to come and see for myself.
I met Charlotte at 8.30 a.m. sharp, in her office, where she was busy with the police summaries for the morning’s cases. There was a man whose body had been pulled from a river; fishing tackle had been found nearby. ‘He might well have stumbled and drowned,’ Charlotte said. There was a woman in her fifties, found dead on her sofa; Charlotte wanted to find out whether the woman had died of a heart attack, which seemed likely, or had been poisoned by gas or drugs. ‘It’s relatively unusual for us to do a postmortem on a woman,’ she said; ‘it tends to be men who die violent or suspicious deaths.’ Finally, there was a man with morbid obesity, found face down in his kitchen, who could conceivably have choked on some food he was preparing. The circumstances of each were detailed in a police report, listing witness statements, some medical history provided by the GP, and also any pertinent information provided by family members. There was a brisk professionalism about Charlotte’s description of each patient, as well as an unmistakable curiosity. She was in the business of looking for answers, and hoped that the morning’s work would deliver them.
I changed into blue hospital scrubs. Between the locker room and the autopsy suite was a tiled tray of the kind used to disinfect your feet at a swimming pool; rubber boots were lined up against the wall, next to a hose for washing them down. The suite was somewhere at the heart of the building and saw little natural light. There were three body-sized steel trays at waist height; when there were enough pathologists around, autopsies could be carried out three at a time. The ventilators in the ceiling were designed to push air down and away from the noses of the pathologists. ‘At least that’s the idea,’ Charlotte said. ‘It doesn’t seem to work very well.’ Along one side of the room was a glass wall with seating behind it: a viewing gallery for students. A fluorescent purple Insect-O-Cutor blinked high on one wall next to a sign: ‘No eating, drinking or smoking.’ We tied on disposable aprons, rolled plastic gauntlets up our sleeves, tucked the gauntlets into surgical gloves, and were ready to start.
The first time I ever saw a dead body was in the first week of medical school, in the dissection room. It was the body of a man, partly skinned. Most of him was obscured under a linen cloth, but his right arm, stiff with rigor mortis, pointed at the ceiling. Preservatives had turned the muscles brown; they spiralled from the hand towards the elbow like ivy around a tree trunk.
In the mortuary, the first dead body – let’s call him Philip – was pulled out on a gurney. No linen cloth had been draped over him, no preservatives had been injected: his skin was grey and mottled, and for the most part intact, except where fish had nibbled. His eyes were half-open, and his head thrown back. The first task of the post-mortem examination was an external search for scratches, scars and injuries. Charlotte carefully examined his hands, nails and feet for evidence of a struggle, and pointed out that his right eye was bloodshot. ‘But look: his arm is reddened on the right too. So it’s only bloodshot from gravity, because he’s been lying on that side after he died.’
Charlotte took a scalpel and made a long cut from the notch at Philip’s throat to his pubic bone, and opened his abdominal cavity. Whether in operating theatres or anatomy classrooms, I’ve always been stunned by this moment of revelation: that just a few millimetres below the skin lies a glistening clockwork intricacy, the mechanisms that keep us alive. Philip had been dead for a few days, and his viscera were beginning to turn – I had to stifle a gag. But Charlotte was deft and businesslike (‘I only wear a mask when there are maggots’);* she cut through his rectum and oesophagus, then lifted out all his major abdominal organs – liver, spleen, stomach, intestines – in one piece and onto a plastic tray. Left behind was a hollow, exenterated space. The tray was placed on an examination table for later, and we turned back to the corpse.
The main artery of the leg enters the pelvis just to one side of the bladder. Charlotte squeezed some blood from it, to be sent away for analysis of drugs and toxins. ‘From my clinic I usually send urine for toxicology,’ I said. ‘So do we,’ she replied. But where I would send the patient off to the loo with a tiny sample bottle, she made a small hole in the top of the bladder with a knife and sucked some urine out with a syringe.
The next step was a delicate dissection of the neck – strikingly gentle after the vigorous opening of the abdomen. There are several layers of muscles in the neck, all of them involved in speech or swallowing. Charlotte peeled away the layers one by one, looking for signs of bruising or haemorrhage – anything that might suggest strangulation. (In anatomy class I was taught the same dissection; like an archaeologist tenderly brushing away earth, the tutor would elevate each strap muscle, eventually reaching the nerve that lies beneath.) There were no signs of bruising or struggle, and the hyoid bone – a C-shaped structure that anchors the tongue – was unbroken. ‘No signs of strangling or hanging,’ Charlotte said. ‘It’s always good to document it if you accidently break the hyoid or the larynx in the removal, just in case the body is exhumed for a repeat examination.’
During the frontal cut Charlotte had left the ribs themselves untouched. Now she used secateurs to cut their front ends, all the way up to the collarbones. She cut those too, and lifted away the breastbone to expose the heart and lungs, gleaming in the chest. The heart is held within a tough membrane called the pericardium; Charlotte took care not to pierce it. Then she nimbly cut a U-shaped slice through the floor of the mouth and, because the neck muscles had already been dissected, she was able to pull the tongue, throat, windpipe, lungs and heart away in one piece.
Philip’s tongue lay on the dissection tray, slippery and purple, still attached to his throat and gullet. Charlotte began to make neat, precise cuts across its length looking for evidence that it had been bitten or chewed – injuries that might suggest the dead man had suffered an epileptic seizure or a biting struggle just before death. The tongue was normal, so she turned back to the table to deal with the head.
While we’d been busy at the dissection tray, the mortuary technicians had cut across the top of Philip’s scalp from ear to ear, exposing the skull, then peeled the forehead skin forwards over the face. The scalp had also been pulled backwards, and the calvarium – the dome-like part of the skull – removed to reveal the brain. Charlotte scrutinised the membranes and confirmed that there was no evidence of haemorrhage or meningitis, then extracted the brain itself for examination.
Our brains can’t bear their own weight out of the skull – that’s why they float in briny cerebrospinal fluid, as the foetus floats weightless in the womb. Charlotte placed the brain to one side, creamy and grey, and it sagged into the contours of the tray. Then she stripped back the opalescent meninges of the skull and we peered into the smooth bowl of its base, where the nerves to the face, ears, eyes and tongue enter and exit. ‘Have you ever seen an acoustic neuroma?’ I asked her – a relatively rare tumour on the nerve running to the ear. ‘Oh yes,’ she said, ‘they’re commoner than you think.’
Charlotte pointed out the pearly translucence of the bone overlying the mechanism of the inner ear. ‘Can you see it looks purplish – that’s blood behind the bone, in the inner ear. You’d think it was a sign of head trauma, but we see that often in drownings.’
‘Why?’ I asked.
‘Gravity,’ she said. ‘When bodies are carried along in the water they usually float head down, and blood within the veins and arteries begins to leak out of the blood vessels and into the inner ear.’*
There were no fractures in the skull that we could feel. The mortuary technicians packed the space with cotton wool and put the calvarium back on. The skin was stitched over as if the brain had never been disturbed.
What was left of Philip lay on the stainless-steel table. All of his major organs had been removed, his abdomen disembowelled, his chest excavated, his ribcage splayed open. Charlotte cradled his head on the now spindle-thin neck, and rocked it gently from side to side, to feel if there were any broken bones. Because his throat and windpipe had been removed it was possible to run a finger along the front of the neck’s vertebrae, to check they were all in alignment. Using a knife, she meticulously divided each rib from its neighbours, and moved it back and forth to feel if there were any fractures. The limbs and pelvis were left to themselves: ‘There’s not much that can kill you in the limbs,’ she said. ‘And now for the cut-up.’
All the major organs were now laid out in a couple of trays (as a medical student, this was the only part of a post-mortem I’d been allowed to see). Charlotte proceeded methodically, at times with extraordinary finesse. There were moments when she slowed down and scrutinised the tissue in her hands as if struggling to read arcane script. Her examination of the heart, for example, involved making scores of tiny cuts through each of the coronary arteries, looking for any clots that might have caused a heart attack. There were moments too when she moved at speed, such as when she bisected each kidney, or cut the liver into broad slabs to look for cancer and cysts. It was surprising how much of the work she did by feel. ‘Some livers are greasy with fat,’ she told me. ‘Feel here’ – she held out a lobe of lung – ‘that rubberiness means it’s infected, but in the healthier tissue it feels airy and light. Emphysema feels different again; too light and airy, like bubble wrap.’ There was a creamy yellow plaque on the surface of one of Philip’s lungs (‘he had probably worked with asbestos’), and Charlotte took a wedge of it away for further examination under the microscope.
Each organ was weighed and carefully catalogued on a whiteboard at one end of the room. ‘We’re so used to the big hearts of overweight men that it comes as a surprise when we find one of normal size. We start thinking there’s something wrong with it.’ Charlotte opened Philip’s heart to examine its chambers, then looked in the pulmonary arteries for evidence of the jelly-like clots of pulmonary embolism. She guided my fingertips onto the lining of Philip’s aorta: it was porridgy, suggesting that he’d had high cholesterol – ‘Another big problem among the Scottish population,’ she said.
The tongue, throat and larynx had already been examined; now Charlotte looked along the length of the windpipe for tumours, then opened it from behind to look for any obstructions that might have caused choking – there were none. ‘There’s not much of interest generally in the abdomen,’ she said, ‘although we do sometimes see tumour seedlings from the bowel, and there are usually plenty of gallstones. See?’ She handed me Philip’s gall bladder: it felt like a bag of dice.
‘Do you ever find anything in the pancreas?’ I asked. ‘Sometimes tumours, sometimes a big gallstone blocks its exit, but usually not much.’ The pancreas generates the enzymes necessary to digest our food, and after death those enzymes are released. As a result, the pancreas auto-digests; the clean contours of the organ transform into liquid as it relents to its constituent parts.*
The long, smooth knives used in autopsies are known as ‘brain knives’ because their principal use is to cut sections through the brain. Charlotte methodically made sections across the brain’s width, starting at the front and moving slowly towards the back, each slice about a centimetre in depth. She did the same with the cerebellum, cutting through the connections that sustained his thought and his identity, hoping to reveal what might have brought about his death. All the sections were then arranged on a slab so that Charlotte could take in the whole structure of Philip’s brain in one glance. The brain was partly decomposed, yet the grey and white matter appeared distinct. There were no tumours, cysts or evidence of bleeding. Charlotte took samples from the hippocampus, and part of the cerebellum (the ‘dentate’). ‘They’re the parts of the brain most sensitive to lack of oxygen,’ she said, ‘so will show if he was struggling for air before he died.’
In the brains of people with Parkinson’s disease, pathologists notice an absence of dark tissue towards the brainstem – the so-called substantia nigra. ‘With vascular dementia,’ Charlotte said, ‘you see little speckles through the brain, and also in chronic carbon monoxide poisoning. In multiple sclerosis there are jellied pink areas, where the nerves’ fatty sheaths have broken down.’
All of Philip’s organs were placed back in the cavities of his chest and abdomen, and the wounds were stitched up until he looked just as he had when he was rolled into the autopsy suite. The samples Charlotte had taken were labelled, and would be sent off for further examination. ‘The toxicology will go off to the lab too,’ she said, ‘and we’ll see whether he might have been poisoned. But often post-mortem is inconclusive. It looks like he had a chest infection, he doesn’t seem to have been assaulted, and there was no obvious reason for a collapse.’
‘So what happens now?’
‘The procurator fiscal will take my report into account, but it’s only one part of the evidence.* It’s up to her to decide whether the death was suspicious, not me.’
I knew the routine now. Taking less than an hour with each, Charlotte performed the same sequence of examinations on the other two bodies. When we opened the skull of the woman in her fifties there was blood: she had died of a massive brain haemorrhage, not a heart attack. ‘What would the actual mode of death have been?’ I asked Charlotte.
‘She’s likely to have died very quickly,’ said Charlotte as she lifted out the woman’s brain; ‘either a rise in pressure within her cranium because of the haemorrhage would mean that blood couldn’t reach and circulate within it, or a brainstem seizure would have terminated her breathing, or even stopped her heart. Look, there’s the ruptured one,’ she said, gesturing among the small aneurysms that hung like grapes beneath the trellis of her brain. It looked like a tiny, deflated wineskin.
The obese man had indeed choked: when we opened the back of his windpipe, we found incontrovertible lumps of potato. ‘And with asphyxiation?’ I asked. ‘How long would it have taken him to die?’
‘He wouldn’t have suffered much either,’ she said, guessing what I was really asking. ‘Forensic studies of asphyxiation have found you lose consciousness within about ten seconds. By twelve or fifteen seconds, seizures begin.’ She went on to explain how, at first, blood would have gone on pumping between the man’s failing heart and his unconscious brain, until a tipping point was reached – oxygen deprivation would have begun to cause irreversible damage to both organs. I thought back to biochemistry class, and how delicately haemoglobin molecules are calibrated to sustain life. By the time he lost consciousness the man’s haemoglobin would have changed from a bright, lava red to a dusky amethyst purple. ‘With less oxygen in the blood, there comes a point when heart muscle can’t carry on,’ Charlotte said; ‘it goes into ventricular fibrillation, and the pulse stops.’
Processes all across the body that for decades had maintained life, stitching it together moment to moment – the filtering of blood in the kidneys, the sifting of toxins in the liver, the maintenance of breath in the brainstem – would have slowed to a stop over minutes. ‘By three or four minutes into an asphyxiation,’ said Charlotte, ‘there are no more signs of life.’
WHEN WE HAD FINISHED the last post-mortem I stripped off my apron, gauntlets and gloves, and hosed down my rubber boots. I stood for a long time in the shower, trying to wash off the smell of human dissolution. I had a clinic to go to in the afternoon, and so changed back into trousers, collar and tie, then went back through to Charlotte’s office. She was writing up her findings. As I walked in she looked up and smiled.
‘So what did you think?’ she asked.
‘You see so much death,’ I said, straightening my tie; ‘how does it affect you?’
She paused, and looked back to her papers. ‘I don’t think about it too much,’ she said at last. ‘But’ – she took a deep breath then smiled again – ‘a morning of post-mortems, it always makes me want to celebrate being alive.’
On the main road outside, a dead rat had been flattened by traffic; a crow was picking at its remains. I got on my bike and pedalled half a mile to my own clinic.
All that afternoon, and for a couple of months afterwards, after-images from the post-mortem room flashed through my memory. ‘Autopsy’ means ‘to see for oneself’ – it felt as if a veil had been pulled aside, and a terrible fragility revealed. I’d be talking with a patient then suddenly imagine them laid out on the mortuary slab, their eyes glazed, their blood cold and dark. Those moments were shocking, but also somehow motivating. Medicine is in some ways the art of postponing death, and I returned to my work with new energy.