Diary

Gavin Francis

Gavin Francis observes the autopsy of a man pulled from a river.

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.”’

Recently, on the phone with a pathologist about a post-mortem report 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,’ she replied. ‘We don’t have all the answers either.’ She invited me to come and see for myself.

The city mortuary in Edinburgh is a dull concrete building, squat and grey with a waistband of windows. It sits on a shadowy street in a district that has long been one of the city’s poorest; tiny cobbled alleys and tenements are knotted around it, and beneath its foundations lie the remains of the city’s 18th-century infirmary. I had passed it hundreds of times, but never given much thought to what went on inside. The little pathology I’d been taught at medical school had taken place in hospital; no one had ever suggested we visit the mortuary.

I met Charlotte Crichton 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. 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.

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 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 the roots of a tree.

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.’

In William Ewing’s book of photo-portraits, The Body (1994), there is an image of a naked woman who looks as if she is sleeping, but closer inspection reveals that her torso has been slit open: a Y-shaped laceration, neatly stitched, a cut from each shoulder joining at her breastbone then extending down to the pubic bone. Charlotte performed the same Y-shaped cut on the drowned man, and opened his abdominal cavity. 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 gossamer-like 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 break the hyoid or the larynx, in case the body is exhumed for a repeat examination.’

During the Y-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 cave of 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 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?’ ‘Gravity,’ she said. ‘When bodies are carried along in the water they usually float head down, and blood under that kind of pressure leaks 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 see 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.

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 the heart to examine its chambers, then looked in the pulmonary arteries for evidence of the jelly-like clots that cause pulmonary embolism. She guided my fingertips onto the lining of Philip’s aorta: it was porridgey, suggesting he’d had high cholesterol – ‘Another big problem among this population,’ she said.

Next she 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 or ovaries, 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 returns 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 – the ‘little brain’ towards the nape of the neck which is involved in co-ordinating movement. 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 the tooth-like (‘dentate’) nucleus of the cerebellum. ‘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, there is an absence of dark tissue towards the brain stem – 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 I could find no obvious reason for a collapse.’

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. ‘Look, there’s the ruptured one,’ Charlotte said, gesturing to the small aneurysms that hung like grapes beneath the trellis of her brain. The ruptured one looked like a tiny, deflated wineskin. The obese man had indeed choked: when we opened the back of his windpipe, we found lumps of potato. When we had finished with him I stripped off my apron, gauntlets and gloves, hosed down my rubber boots and took a shower, hoping I could wash away the smell of human dissolution.