The Chick and the Dead

by Carla Valentine

  * * *

  I’ve since researched secrecy and transparency in all aspects of the death professions: mortuary work, funeral work, skeletal excavation, public display of human remains and more. It is often fragments of the human being that I tend to focus on, given my position as technical curator of a pathology collection, but I also keep up to date with studies on mortality salience (our understanding of death), death theory and constantly changing legislation regarding the dead. Back then, during that difficult time, I needed something to focus on in my evenings, so I began to read more of my old books and acquire some of the classics such as The Denial of Death by Ernest Becker and The American Way of Death by Jessica Mitford. I connected with people on social media who felt death shouldn’t be kept behind closed doors, quietly following the ‘Death Positive’ movement revived by an insightful and humorous mortician from the US, Caitlin Doughty, who wanted death to be talked about in the open; to do for mortality what the earlier ‘Sex Positive’ movement had done for sexuality.

  I began to form my own theories as I learned about the benefits of open communication about death. After all, it was secrecy which led to the organ retention scandal, and an attitude of ‘tell them as little as they need to know’ which caused so many problems further down the line. I attended conferences in different cities and met up with some of the people I’d been chatting with online. At one conference I heard of a fascinating study called ‘Bones without Barriers’, which encompassed everything I was trying to argue for. In a nutshell, a team of archaeologists erected screens around their excavation site and began to exhume skeletal remains. The local residents weren’t happy: they wondered what was going on ‘behind the screens’ and in the absence of any actual knowledge they feared the worst, imagining the excavation to be a desecration of people’s graves and that there was no real reason for it to be done. The insinuation was, if they weren’t up to no good then why hide what they were doing? After a certain amount of time the second part of the study commenced. This involved removing all the screens and allowing the general public to approach and ask the archaeological team questions; in some cases they were even allowed to handle the bones. Questionnaires revealed that the public had been much happier about the excavation during the screenless phase: they understood the procedure more and were interested in what was going on rather than offended by it.

  The study opened my eyes to a world out there that might still involve me using my skills but being able to communicate about it. I didn’t quite know what I wanted to do yet, but I could feel all my own fragmented pieces coming back together again as I began to focus on that aim. I was tired of being in a profession in which I was told ‘You’re not supposed to talk about your day unless it’s with a long-term partner or a parent. Don’t discuss it with just anyone.’ I was tired of the fear of God being put into me about making a mistake because if I did ‘it’ll be another Alder Hey’. I was tired of even hearing that phrase!

  The paperwork increased, but I felt like it wasn’t relevant; it wasn’t progressing my or many APTs’ general aims. I would have liked to attend quarterly APT meet-ups and contribute more to our organisation, the Association for Anatomical Pathology Technologists (AAPT), but instead I was responsible for things like ensuring that the whole pathology team, including all the doctors, were carrying out their Manual Handling and Health and Safety training. I may as well have been working in clinical governance.

  Still, I took it all on board as ‘experience’, but even though I increased my hours I couldn’t quite keep on top of it all. Then I realised another reason why I’d wanted to stay with Railway Man and reconstruct him no matter how long it took: I had wanted to stay in the little High Risk PM room. I didn’t want to come out and work in the office. I wanted to do the thing I’d wanted to do since I was a child, the one thing that never seems to get mentioned by other APTs – I wanted to work with the dead.

  That was when I knew I had to leave.

  * * *

  Whilst looking for other jobs, I made sure I spent as much time as I could in the post-mortem rooms. There was always something to be learned from veterans of pathology like Professor St Clare and many of the other consultant pathologists who would come on a rota system to carry out the day’s cases. Not all mortuaries work the same way so I made sure I was registered on a database for locum APTs so that I could use my annual leave, or time between jobs, to work in other facilities. And I did look for managerial jobs in other mortuaries because smaller (particularly local authority) ones tend to have a lot less paperwork and the manager will carry out more autopsies. There were other death professions I was looking into as well – ‘there’s more than one way to skin a cat’, they say. In fact, there’s more than one way to skin a human being. I found this out as part of my ever-expanding research …

  One afternoon, we had a phone call which Tina answered. As she listened to the voice on the other end I could see her looking more and more forlorn.

  ‘What is it, Teen?’ I asked, after she’d put the receiver down. ‘Last-minute viewing or something?’

  ‘No, it was the tissue bank. There’s a skin and bone donor here and they want to do it this afternoon.’

  ‘Why is that a problem?’ I asked, curious. I’d never seen it done before.

  ‘Because it takes for ever,’ she groaned. ‘I’m on call but I’m supposed to go to a meeting with Juan and the clinical governance team. The tissue people can’t do it unsupervised – someone needs to be in the office, able to pop in and out of the PM room.’

  ‘I’ll stay with them,’ I offered. I probably wouldn’t stay in the office, I’d go in and watch the process.

  ‘Really? You’d do that?’ asked Tina.

  ‘Of course! I want to see how they do it, anyway. Don’t worry about it – go to your meeting.’ It seems Tina was way more cut out for the clinical governance life than I was.

  So, an hour later, I was happily ensconced in the post-mortem room with the technicians from NHSBT Tissue Services explaining the procedure they were about to carry out. They were both so cheerful! Johnny, plump, with brown hair and about thirty years old, was happy to answer all of my questions because the younger girl he was with, Sonya, was his trainee. She was able to learn some new things during the discussion, too.

  ‘So you had to come and do this today – it couldn’t be put off until tomorrow?’ I asked as I removed the donor from the fridge. ‘I mean, not that it’s a problem – I just wondered.’

  As we moved the donor into the PM room, Johnny explained, ‘We have up to forty-eight hours to remove most tissues but if the donor has ticked this consent box’ – he pointed to a specific part of the paperwork – ‘then we really want to come and get them as soon as possible, certainly within twenty-four hours if we can. They’re more likely to be successfully transplanted if they’re harvested sooner.’

  ‘Harvested’ is the technical term for removal of any tissue from a cadaver in this context. The tissues he was referring to were skin and bone in this instance, and anyone can tick the box to donate them after their death. (Tendons and heart valves can only be donated by those under sixty years of age). However, just like with other organs, it doesn’t necessarily mean the tissue will be used: it can depend on factors like whether or not an infectious disease is present or whether it’s too damaged by injury. Of course, decomposition is a factor, too. That’s why there needs to be an excess number of donors out there, more than we actually need.

  ‘A lot of people don’t know that even if they’re alive they can donate skin,’ Johnny added, slipping into his PPE. ‘You know, if someone loses a lot of weight and has excess skin surgically removed?’

  I hadn’t even known that. As usual, I was just focused on the dead. ‘That’s a really good idea – I’d never have thought of that,’ I answered as I watched him open his ‘harvesting kit’.

  He pulled out an instrument that looked like a large stainless-steel razor with a clunkier head. It had a cable attached
to it, and he plugged it in.

  ‘This is a Dermatome – it’s like a big razor with an oscillating blade,’ he said as he examined the deceased to see which skin parts were best to harvest. Obviously nothing visible that would alter reconstruction – mainly his thighs. The Dermatome buzzed, and because it was electric it enabled him to remove rectangles of skin of a uniform size and thickness, unlike manual ones which he told me could be a bit more irregular.

  It was so incredible watching him remove these long swathes of skin from the deceased, the hair still attached and glowing under the fluorescent lights, before handing them to Sonya to be placed into special packaging.

  ‘What happens to them afterwards?’ I asked, utterly rapt.

  ‘Once they’ve been treated they get placed on a meshing device which basically turns them into nets.’

  It’s these nets of skin you see grafted on to individuals who’ve been extensively injured. Common uses for them are burns, skin infections and bedsores or ulcers that haven’t healed well. Had my anorexic dentist survived his septicaemia he probably would have needed grafts like this.

  As Johnny worked and chatted he made the procedure sound so modern, with his electric tools and sentences peppered with the words ‘cryopreserved’, ‘irradiated’ and ‘antibiotic incubation’, but accounts of skin grafting have been found as early as 2500 years ago, in India.

  But there’s another use for this cadaver skin, something I didn’t know about until a couple of years later. I mentioned I have a facial condition called Parry-Romberg Syndrome, which is quite rare. I talk about this and any other health issues I’ve had simply to illustrate that even though I work in pathology that doesn’t give me a ‘get out of jail free’ card when it comes to my health; we’re all people, prone to the effects of pathology’s capricious nature. I’d love it if my decision to work in this field had involved me making a dark pact with the Grim Reaper to ensure me and my loved ones immunity from death and disease, but unfortunately that’s not the case. It’s a shame really. I’d like to do something dramatic like sign a scroll of parchment in blood … or would it in fact be a scroll of skin, removed using an infernal antique Dermatome? We’ll never know.

  Anyway, my particular condition, also known as hemifacial atrophy, was caused by physical trauma – I wasn’t born with it – and, among some other more serious symptoms, it makes my face asymmetrical. The tissues basically dissolve on one side. Every year or two, like a car having an MOT, I go into hospital for surgery to even out my facial structure. My surgeon had previously removed those pieces of my fascia and my own body fat but they too had dissolved after they’d been implanted in my face for a while. The next attempt, he’d said with some gravity, was to use ‘Alloderm’, which was cadaver skin. When he uttered that phrase he looked at me as though he was expecting a peal of thunder.

  ‘OK,’ I said, unperturbed.

  ‘It may well be more stable,’ he added, so quickly I assumed he was worried I’d change my mind. ‘I would have mentioned it sooner, but I didn’t want to scare you off with the idea.’

  ‘Oh, for goodness sake, Mr Mahmoud, I work in a mortuary! I don’t mind a bit of cadaver skin in my face!’

  And that was how I came to be the Bride of Frankenstein, physically reconstructed from the parts of the generous dead.

  Back in the post-mortem room, Tissue Services were now hard at work removing the bones from our donor, namely the femur, tibia and fibula in the legs. This involved creating a deep incision into the flesh of the leg, much deeper than an APT would usually need to go, and cutting right through the fascia, which was amazing for me to watch considering I had half of my leg fascia in my face but had never actually seen it. The bones were replaced with silicon rods of the same dimensions so the legs didn’t end up ‘floppy’. ‘They used to use sawn-off wooden mop handles before these, you know,’ Johnny told me. It made sense. A lot of things used to be made of wood.

  The procedure was similar to when we APTs made an incision into the deceased’s calf muscles to check for deep vein thrombosis (DVT), a condition many are familiar with because of its association with flying (though it’s more to do with being immobile for long periods of time). If a clot or coagulated blood embolism forms in the leg vein and part of it breaks off, it may circulate through the body and end up in the lungs, causing a fatal pulmonary embolism. If the pathologist found such an embolism, also called a PE, I’d then inspect the muscles of the calf to ascertain its origin. Sometimes it was visible to the naked eye which calf contained the DVT as it was slightly swollen, but other times I’d just have to delve. The difference is I’d be searching in the vessels of the calf muscles and not incising quite as deep into the bone. But despite the difference in depth, Johnny reconstructed the incision in exactly the same way as we did.

  ‘Oh look, he’s an eye donor as well,’ Sonya pointed out, seemingly pleased that she’d noticed this on the form.

  ‘I can remove eyes!’ I exclaimed, like a kid on the front row in the classroom. ‘Well, I have a certificate … I haven’t actually done it yet,’ I admitted.

  ‘Do you want to retrieve these?’ Johnny offered. ‘Sonya has to watch anyway – she hasn’t done the course yet.’

  ‘Oh God, no, I can’t remember how I did it now.’

  ‘Well, how about I do the first one, you watch, then you do the second?’

  I was shocked. ‘You’d trust me? What if I ruin it?’

  ‘You eviscerate whole bodies, don’t you?’ he pointed out. ‘I’m sure you can manage one eye.’

  Fair point.

  So, after observing Johnny deftly remove the left eye, drop it in a container of sterile solution with a muted ‘plop’ and place it straight on ice, I took a fresh scalpel and removed my first eye. To do so I had to open the eyelids with metal retractors as he had done, creating a slightly harrowing tableau which reminded me of A Clockwork Orange. But it meant I could access and slice through the conjunctival muscles and optic nerve with the disposable scalpel, as easy as a knife through butter. Within seconds the right eye was also on ice and ready to go to one of two main tissue banks in the UK, where it could be stored for up to thirty-eight days. I reconstructed the socket by fashioning a spherical wad of cotton wool the same dimensions as an eyeball and then placing on a smooth plastic eye cap for roundness. Once re-dressed the man looked exactly as he had before. The fact that these tissues had been harvested wasn’t obvious at all – he was perfectly reassembled.

  * * *

  The bodies of the deceased who were severely decomposed – the ‘decomps’ – were reconstituted in the exact same way as everybody else. There was no way they would usually be viewed by family members – our current aversion to decayed cadavers in the West has made it highly unlikely. On the odd occasion when family members insisted on viewing their decomposed dead – and by ‘insist’ I mean literally refuse to leave the building without seeing them – in some mortuaries we had to make them sign a waiver. The form basically stated that we had informed the next of kin of the condition of the deceased – the colour, the smell, the fact that this will not look like the person they remember – and they had accepted that and were still prepared to go in.

  The decomposed will also under no circumstances be embalmed because they’re too decayed. The fragile veins would be unable to withstand such strong chemicals and the colour changes I’ve already described can’t be altered, either. But that’s not the point. We reconstruct the dead for the dead. The decayed dead deserve the same treatment as everyone else so we still place the organ pulp into a viscera bag, still fill the skull with cotton wool and close the scalp, and still attempt to stitch the leathery skin of mummified remains back together, even if their desiccation and shrunken state means there’ll be a gap. We then sprinkle an absorbent, scented powder into the bag, zip it up, and usually place that into another bag. And then another one. And if there’s someone around to pay for a funeral they will have a closed-casket ceremony regardless of whether they’r
e buried or cremated.

  * * *

  The dead can’t be reconstructed perfectly, and perhaps that’s the point – they’re not supposed to be. Although we in the West only see decomposing cadavers in horror films and computer games, that certainly wasn’t always the case.

  Thirteenth-century Buddhists practised their Nine Cemetery Contemplations, or Maranasati meditation, with the help of artwork depicting all aspects of human decomposition. These pieces, known as kusozu, were a visual aid to assist the Buddhists’ reflection on the various phases of death and were still popular in the nineteenth century, and in recent times I have had Buddhists ask to view my museum specimens for the same purpose. The ultimate aim of Maranasati is to appreciate mortality and to accept the changing nature of all things, therefore increasing mindfulness. As these decomposing corpses tended to start out as beautiful courtesans in the artwork, there was also an element of enforcing chastity among the monks during these meditations, the idea being that her outside form may be beautiful, yet underneath it all she will rot and decay like everyone else.

  It’s the same lesson I took from this multitude of decomposed decedents. It’s very difficult to hold on to the idea of the importance or significance of the minutiae of the day when faced, literally, with a decomposing human. The Buddhists teach impermanence, the notion that all existence is transient or in a constant state of flux. That transience is there before your very eyes in the changing state of the deceased – it exists in a liminal space, not really dead and not really alive. The process is nature’s great leveller. The Greeks and Romans slept in tombs to receive inspiration from the dead, and the same lesson was taught in the West via medieval art, whether paintings or sculptures, which showed skeletons crawling with what they called ‘worms’ as well as other insects. The painting Allegory of Death by the circle of Juan de Valdés Leal is very typical of the era. It depicts a skeleton, somewhere between advanced decay and dry remains, reclining with its guts hanging out and beetles munching at exposed leg bones. Their ‘transitional nature’ – deceased yet teeming with life – means that models of rotting carcasses, popular in the later medieval era, came to be known as transis. A transi can be lifesize and carved in stone or tiny and made from ivory; either way, it is a memento mori, a reminder that death comes for us all and decay is natural.