In forensic cases, after the pathologist has carried out the external exam, it is he who also carries out the evisceration. Everything on or in the deceased needs to be noted by a medical doctor qualified in Forensic Pathology as they may need to testify in court. It’s not a responsibility APTs are trained for. One thing we still do, however, is dissect the head to remove the brain, but in this case I assumed it wouldn’t be requested. The man had been murdered – someone had chopped his head off with a very sharp blade – and it was now up to the police to discover who did it. When they eventually did, the pathologist would be called to present his findings to a jury in court.
Case closed, hopefully.
Imagine my surprise when Dr Colin Jameson said, ‘OK guys, you can crack on with the head.’
I looked at Jason, eyes wide with fear, thinking, ‘How the hell are we going to do that here?’ As if Jason could read my mind, he said calmly, ‘Right, you get the saw and I’ll hold him.’
I moved closer to Jason and whispered that I didn’t feel comfortable wielding the cumbersome saw in front of all these people – I was still a trainee at the time and I was used to my heads being attached to something.
‘OK, you hold him and I’ll saw,’ he said. ‘But you really need to hold on tight.’
So I found myself across the post-mortem table from Jason, holding a heavy, decapitated head aloft, manoeuvring it into the right position then keeping it steady on the stainless steel. I needed to be careful that my fingers didn’t stray past the deceased’s ears because I would have lost them to Jason’s scalpel so, weirdly, I had to hold this decapitated head like I would a lover: by placing both hands on his cheeks. I then had to lean forward and rest my elbows on the steel in order to balance myself and strengthen my grip. I was staring directly into the eyes of this severed head as though I was about to kiss him, just like Salomé, and there were around twelve pairs of eyes on me as I carried out this odd and intimate task. As if that wasn’t bad enough, my bottom was in the air. It would have been like a comedy sketch if the circumstances hadn’t been so harrowing.
Jason was right. As he made the incision and reflected the scalp I found I was capable of holding the head steady, but as soon as he started to saw I just didn’t have the strength to compete with it. The sheer force of the machinery kept making me tilt the head so Jason couldn’t create a straight line. So we had to swap, and I sawed through the skull while he held the man’s head with his body-builder’s hands and forearms. Eventually we had the calvarium off and the brain in the scales and, sweating and red-faced, I felt like I’d passed some sort of test. Reconstruction was going to be interesting …
One other thing that was odd (as if the whole situation wasn’t bizarre enough) was the removal of the neck and tongue organs, or what we call the pharynx – the throat. There are a couple of ways to do this. When I did a typical Y-incision on a decedent propped up on a rubber block, it created a triangular flap of skin over the whole neck, the ‘point’ of which was near the middle of the clavicles. You can feel the place yourself as the dip between your own collarbones – it’s called the suprasternal notch. I’d take the tip of this skin triangle between my fingers or toothed forceps and pull upwards towards the face, all the while freeing the white connective tissue clinging to the sternocleidomastoid (SCM) muscles of the neck in the same way the scalp clung to the skull. It took just a feather-light touch of a sharp scalpel to help me progress. I’d continue this way until the jawbone of the deceased was visible like a large white wishbone, and the neck muscles completely uncovered. Then, taking a PM40, I’d slide the blade under the jawbone (into the mouth – I could see the shining blade skimming behind the teeth) and cut along it from one end to the other, allowing me to pull the tongue down and under the mandible. I’d then slice across the back of the mouth and pull all the neck structures away from the bone – tongue, larynx, trachea, SCMs – just working my way down and eventually revealing the vertebrae behind the tissues.
However, a straight or I-incision stops at the suprasternal notch so this process is infinitely more difficult. Effectively I’d have to carry out the whole process blind. Because I couldn’t cut the skin of the neck I had to force the PM40 beneath the neck skin, find the jawbone with the blade and cut along it without seeing what I was cutting, using the bone as a guide. All the while I’d have to make sure I didn’t perforate the neck skin, therefore making the whole point of the straight incision useless. (Although that superglue I mentioned was definitely a lifesaver when it came to nicks like that, which we called ‘buttonholes’ – it could make an incision practically invisible or simply look like a natural wrinkle.)
But what were we to do in this situation? The poor man’s tongue and half his pharynx were in the head and the rest of it was in the body.
I just said to Jason, ‘Bagsy the body,’ since that was completely opened. I’d let him struggle with trying to remove half a pharynx from a decapitated head in front of all these glaring eyes.
We remove the neck and tongue routinely in autopsies for many reasons; nothing is done gratuitously. First we check in the mouth to see that there is no food or other foreign matter, which could indicate choking. But superficially looking into the mouth cavity is not enough. By removing the pharynx the pathologist can open it up to see if there’s a bolus of food stuck in the oesophagus or the trachea. For example, some onlookers may witness what they think is the victim of a cardiac arrest but at autopsy we discover cause of death to be what’s known as a café coronary. This occurs when an intoxicated person chokes on her food and the natural gag reflex is suppressed by the alcohol in the blood. (Now you see why food and death are so interconnected for me – there are just so many associations!) The tongue can also be checked for artefacts like bite marks: if a decedent bit their own tongue they may have had a seizure. The delicate cartilage and hyoid bone of the larynx may be damaged in the case of mechanical choking by another individual, and classically, the way to determine if a victim of a fire was alive during it is to find sooty deposits in the trachea which indicate breathing in smoke. There is so much to be discovered just in that one small part of the body which not many people realise we remove at autopsy.
* * *
Perhaps, then, one of the most important things when working in a mortuary is being able to ‘keep your head’, to focus in the face of some of the strangest or most gruelling deaths that can be experienced. It’s bad enough reading about some cases in the paper; imagine what it’s like for the families of the victims and for those in the death industry who see everything right there in front of them. Up until the later part of my career I felt like I’d been keeping a fairly good balance, teetering on the edge of the two abysses: one, caring too much and having a nervous breakdown, and the other, caring too little and becoming callous and detached. But recent events in my life had started to make me rethink my job. I no longer felt balanced enough to deal with the stresses coming my way. I was, in effect, starting to lose my own head.
Nine
Fragmented Remains: ‘Bitsa’
Bitsa this, bitsa that. Put ’em all together and what’ve you got?
—Bitsa (kids’ TV show theme)
In southern Africa there is a form of traditional medicine which sometimes rears its ugly head among the populace. It’s a type of witchcraft containing rogue aspects as well as the traditional medicine magic, ‘Muti’, said to be extremely potent because it requires body parts of the dead. The only time Muti becomes familiar to the mainstream in the developed world is when a ritualistic ‘medicine murder’ hits the headlines. Take, for example, the heinous case in 2001 of the ‘Torso in the Thames’, in which a small, headless and practically limbless torso was discovered in London’s famous river, still wearing a pair of orange shorts over the stumps of his legs. Realising it was the body of a child and unwilling to allow him to disappear into obscurity, investigators decided to name him Adam. It required scores of experts deploying a multitude of analytical and investiga
tive techniques to uncover some truths about the unidentified remains. A sophisticated analysis of Adam’s bones for trace minerals absorbed from nutrition revealed levels of strontium, copper and lead two and a half times higher than would normally be expected in a child living in England. From that analysis, forensic geologists gradually narrowed down Adam’s likely origin to West Africa, probably Nigeria. Then forensic work carried out by botanists at Kew Gardens identified unusual plant extracts found in Adam’s intestine as those which grow only in the area around Benin City, the capital of Edo State in southern Nigeria. It took many years, but Adam was eventually tentatively identified as Patrick Erhabor, and he was no longer just a torso. It was claimed he was a young boy who had been trafficked to the UK from Nigeria specifically for a ritual sacrifice.
The case lifted the lid on abhorrent Muti practices, such as the kidnapping and murder of a ten-year-old South African girl, Masego Kgomo, in 2009, which happened in order to sell some of her body parts to a sangoma, a practitioner of the tradition. This case sparked calls to sangomas to stop the practice.
Only two years ago I nearly spat out my coffee while checking my morning news alerts before heading into work: the headline screamed ‘Genitals Stolen from Morgue!’ Upon reading it, I discovered that the breasts and labia had been removed from the dead bodies of two elderly women in Durban, South Africa, and the writer speculated that the crime was Muti-related. According to another article, ‘it is often soft tissues such as eyelids, lips, scrota and labia which are excised from the dead for these practices’ – practices which clearly still continue.
* * *
When I first began working in mortuaries I was usually confronted with the totality of death – and the deceased – as a whole. It isn’t commonplace in the UK to experience cases which involve fragmented remains, although in other parts of the world the likelihood may be higher. Therefore, I never really considered people in pieces – not until the morning I opened the furthest door of the fridge unit at St Martin’s and discovered a large, bright-yellow plastic tub. It was about two feet high by three feet wide.
‘This is a pretty big sharps bin!’ I shouted to Sharon. ‘What’s it doing in the fridge?’
A sharps bin is a bright-yellow plastic container used specifically for the disposal of scalpel and PM40 blades, as well as needles from syringes and even broken glass. It basically does what it says on the tub, in big black letters. But I realised this huge version didn’t have ‘Sharps Bin’ written on it, at about the same time as Sharon walked over to see what I was referring to.
Her throaty laugh echoed around the fridge room before she answered in her comforting cockney accent, ‘What are you like, Lala? That ain’t a sharps bin!’
‘Well, what is it?’
‘It’s a limb bin.’
Situations like this are one of the reasons I love working in different mortuaries. No matter how much you think you know, there’s always something else to learn. A limb bin, I discovered, is a temporary storage unit for parts of bodies that have been surgically amputated – meaning they’re usually found in hospitals. Amputation occurs more frequently than you might assume: for example, after an accident if a person’s hand or arm has been damaged beyond repair, or, in the case of diabetes, when peripheral arterial disease (PAD) causes blood loss to the foot and lower leg, and ultimately ulcers and necrosis.* Although the patients usually haven’t died from the procedure there’s nothing that can be done with the appendages, so they’re brought down to the mortuary on adult stretchers covered in a white sheet. They are then unveiled by the porter assigned this odd task, with an ostentatious flourish, as though he’s in a posh hotel delivering room service to Hannibal Lecter.
‘Can I see inside?’ I asked. I imagined the contents to be something Dr Frankenstein would keep in his turret-based laboratory, picturing in my head a mish-mash of arms and legs crossed over each other, hands intertwined around feet, and maybe the odd finger or toe. In my head I heard John Goodman in The Big Lebowski saying, ‘You want a toe? I can get you a toe.’
‘Course you can,’ said Sharon as she removed the lid.
I peered over the top, like a child would with a toy box, but I was slightly disappointed. Of course, the limbs weren’t just flailing about like some nightmarish vision from a Marquis de Sade novel; they were all wrapped up and neatly packaged, looking more like parcels in a mail room. I learned from Sharon that once the bin is full, all these extraneous body parts are sent to be incinerated in the bowels of the hospital. At the time I thought, ‘What a waste.’ I don’t know what I was envisaging could be done with these leftover limbs, because creating a monster à la Dr Frankenstein was obviously out of the question – not enough thunder and lightning in the UK, for a start – and I supposed they weren’t suitable for trainee doctors to practise dissection on because they had far too many disfiguring injuries. It’s only very recently, 2016 in fact, that a genius use for these wasted limbs was proposed.
In the UK we do not have forensic taphonomy facilities, colloquially known as ‘Body Farms’ (the first and most famous one was created by forensic anthropologist Dr Bill Bass in Tennessee). These facilities are vital for gathering data on the various ways a cadaver can decay, and this data can be used to try to pinpoint time of death and therefore possibly establish or destroy the alibis of perpetrators of crimes. At the moment our laws in the UK do not permit such a facility, and instead we use pigs.
But humans aren’t pigs. OK, some are, but not physiologically. Recent studies at that Tennessee facility compared pig to human decomposition and the rates are not the same – in fact they vary wildly. This has serious negative implications for the use of pig data in courts worldwide. Quite simply, we can’t keep using pigs as human analogues for forensic taphonomy research – that is, the study of burial, decay and preservation. So a leading forensic anthropologist, Dr Anna Williams, and her student, cadaver dog expert Dr Lorna Irish, proposed a fantastic idea: what about populating a ‘Body Farm’ with human limbs and tissue removed surgically, instead of allowing them to be incinerated in our limb bins? Their decay rates could be studied and cadaver and victim recovery dogs could be trained on the real thing.
I undergo facial surgery quite frequently. I suffer with a rare but non-life-threatening neurocutaneous disorder called Parry-Romberg Syndrome which means I’ve had pieces of muscle fascia (a collagen-rich connective tissue which surrounds the muscles) removed from both my thighs and temporal muscles and implanted into atrophying parts of my face. It wouldn’t have bothered me if any of my surplus tissue from these procedures had been used for research in the above way rather than simply being incinerated; indeed, I’d have liked an option to say so. I may well be a scientist fighting on the side of forensics progress, but I’m also a patient. I’m human, made of flesh and bone, and helping other humans is a priority.
An article about this proposal stated, ‘This new suggestion of allowing volunteers to donate body parts following operations is being seen as a “halfway house approach”, which scientists claim could prove invaluable in advancing forensic work.’ It would be one step closer to using whole donors and one step closer to smashing the taboo of using the dead for research. A survey carried out within the article showed that 94 per cent of respondents considered it a good idea, agreeing with the comment ‘If they’re going spare, why not?’ Only 6 per cent found the idea ‘gruesome and creepy’. Perhaps the notion that these human remains aren’t from deceased individuals removes some of the stigma, especially that left by the organ retention scandal and Alder Hey, and makes it easier to swallow?
Actually, ‘easier to swallow’ is a poor turn of phrase to use when talking about amputated extremities. At the Pathology Museum, when I teach the history of ‘potting’ human specimens from the 1600s onwards, I discuss the first preservative used for teaching – alcohol, also known as ‘spirits of wine’ – and bring the process right up to date with an imaginary trip to the Yukon, in Canada. In Dawson City there is a
bar called the Eldorado. In this bar, a drink of any choice of alcohol containing a real severed human toe is served to patrons who want to take part in the Sourtoe Challenge. The rules are, ‘You can drink it fast, you can drink it slow, but your lips have gotta touch the toe!’
The story began in the 1920s when rum-runner and miner Louis Liken had his frost-bitten toe amputated and he decided to keep it as a souvenir in alcohol, as you do. Many years later, in 1973, Yukon local Dick Stevenson found the toe and thought, ‘Hey, why not put it in a drink and create a challenge?’ Again – as you do. Thus the Sourtoe Cocktail was born, and to this day those who manage the feat of drinking one are presented with a certificate stating that they belong to the Sourtoe Cocktail Club. However, disaster struck in 1980 when a challenger’s chair tipped back as he was drinking and he swallowed the toe. Records state that ‘Toe Number One was never recovered’!
The Chick and the Dead Page 18
