Unnatural Causes

by Dr Richard Shepherd

  ‘And, remember, Dick, those gloves also show you where your fingers are …’ were the final words of helpful advice from the staff as I passed the fridges and entered the post-mortem room.

  The patient was a middle-aged woman who had been admitted to the hospital with severe chest pains and had then died on the coronary care unit some days later. The mortuary staff had her waiting for me on a porcelain table. She was still wearing her shroud. Wrapping bodies really neatly in tight sheets used to be one of the great nursing skills, like making a bed with hospital corners, but it is seldom if ever seen now. It gave respect to the dead but exasperated the nurses: it could take them an hour or so to shroud a body well, only for us to simply pull the sheet off in the mortuary to perform the post-mortem. No wonder busy ward staff abandoned all that linen origami and started using simple paper shrouds instead.

  The mortuary staff removed the shroud to reveal the body.

  I stared at her. Anatomy dissection had been one thing, with its dead bodies so long pickled and grey that it was possible to forget they had ever been alive at all. But this was quite another thing. Here was a fresh body. Here was a woman who, within the last twenty-four hours, was living and breathing and talking to her family and to her doctors. According to her notes, she had said she was determined to get better and go to her granddaughter’s wedding in a month’s time. And then was dead within the hour.

  In fact, she looked really rather healthy and not very dead at all. I had the uncanny feeling that she might wake up at any moment. And I was going to cut into her pink flesh. Run a knife right down her torso and then open her. Surgeons, of course, do just that, but for surgeons there’s a good reason, at least in theory: they are trying to save a life or improve its quality. I could make no such claim. At that moment, I wondered if I didn’t have more in common with a homicidal maniac than a doctor.

  My older colleagues stopped joshing and watched me closely as I carried out my external examination of the body, looking for marks and any indications of the cause of death.

  I’d always wanted to do this. I’d worked hard to arrive at this point. But now, suddenly, my ambition to become Keith Simpson and specialize in forensic pathology to help solve crimes seemed a schoolboy fantasy. The woman lying motionless on the porcelain table in front of me was the reality. Whatever had possessed me? I must have been insane to want to do this.

  ‘OK?’ asked a voice. Humour had been replaced by concern.

  I took a deep breath, steeled myself, picked up the knife and placed it at the little notch in the centre of the base of her neck between the inner ends of the collar bones. Her skin did not resist as I pushed on the blade. I pulled it through the midline. Firmly because I was trying to stop my hand from shaking. Down, down, right down the body to the pubic bone.

  My second cut along the same line took me through a layer of bright yellow fat. The patient was overweight. Fat solidifies and becomes more fixed to the skin once the body has cooled down in death and it can simply be peeled away. Underneath is the muscle layer and beneath that is the ribcage of the thin person who is always there inside that round body – but hidden.

  My next cut was also easy, the cut through muscle. It is hard to believe how much like the carcases hanging at the butcher’s the human body looks when stripped down to the bone, and how like a steak human muscle can appear.

  Now I could fold the skin sideways and outwards from the midline, as though opening a book. Even with a breast each side, this is easy. The main problem was to make sure my knife didn’t cut through the thin skin around the neck: if her relatives paying their last respects saw this, it would look shocking to them, like a stabbing. In fact, mortuary staff are highly skilled at repairing the mistakes of junior doctors – but it would cost me a bottle of whisky, something I could ill afford.

  Once the skin, fat and muscle are pulled back it is easy to cut through and then remove the front of the ribs. And when I had done this, there before me were this woman’s internal organs laid out for my inspection.

  Her lungs looked purple and swollen. They were flecked with soot.

  ‘Hmm, looks like a smoker,’ said my older colleagues, shaking their heads in disapproval. While they hid their nicotine-stained fingers.

  ‘But the purple colour suggests oedema,’ added one.

  ‘Pulmonary oedema …’ I echoed nervously. That meant the lungs had become waterlogged with fluid. This can happen when the heart is failing from disease but I knew it very often happens during the actual process of dying as the heart finally fails. Since death can be caused for one of a thousand reasons, waterlogged lungs alone are not usually helpful for diagnostic purposes.

  I opened the sac inside which the heart nestles. It is just to the left side of the chest.

  ‘No blood or excess fluid. But it looks like she’s had a massive infarct,’ I said quickly, before anyone could tell me. About a third of the muscle at the front of the heart was distinctly paler than the rest, indicating that it had been deprived of its blood supply and oxygen. A myocardial infarct, colloquially called a heart attack, is the death of heart muscle: if the patient survives the initial damage then eventually the muscle becomes scarred. But this heart attack was too recent for scarring.

  ‘What was her blood pressure the last time it was taken?’ they asked me.

  ‘High. 180/100.’

  ‘High blood pressure … oh, and she was such a big-hearted woman,’ hinted the others.

  It looked like a normal heart to me.

  ‘Is it enlarged?’

  ‘Wall of the left ventricle seems a bit thick … weigh it.’

  The heart weighed 510g. That’s huge.

  They said, ‘What do you think?’

  ‘Um … lungs full of fluid. High blood pressure, left ventricle enlarged and an infarct. One of the coronary arteries is blocked by thrombus.’

  ‘Yes. But which one?’

  Back to Anatomy class. The anatomy of the heart. For my own personal reasons, I’d spent a lot of time studying this organ. Its structure. Its pathology. Its associated pathogenic mechanisms. Its arteries. Its valves. Especially the mitral. Yes, I knew about hearts.

  ‘There should be a blockage in … er … the left anterior descending artery?’

  They nodded. ‘Take a look!’

  I did, and there it was. A big, red, solid clot that had halted blood flow along the artery, depriving the heart muscle of the blood and oxygen it needed. And so, it had simply died.

  What a remarkable mechanism the human seemed to me that day. As my fear drained away I became absorbed in my work. But I still had time to experience that sense of wonder at the body: its intricate systems, its colours and, yes, its beauty. For blood is not just red – it is bright red. The gall bladder is not just green, it is the green of jungle foliage. The brain is white and grey – and that is not the grey of a November sky, it is the silver-grey of darting fish. The liver is not a dull school-uniform brown, it is the sharp red-brown of a freshly ploughed field.

  When I had finished examining each organ and they had all been replaced in the body, the mortuary staff moved in to work their magic of reconstruction.

  ‘Well done,’ one of the senior trainees said. ‘Wasn’t so bad, was it?’

  It was over and I had been slow – it was well past lunchtime – but I had done all right. I had put my feelings about older women with heart problems to one side and had recalled my training and then conducted myself in an entirely clinical way. As I washed afterwards I felt flushed with relief. I was a horse that, after racing round the track for years and years, had been nervous about facing a hurdle – and then had easily cleared it.

  The post-mortem turned out not to be the hardest job that day. Meeting the deceased woman’s relatives was far more demanding. Given a choice, I would have preferred not to see them at all. But they had sensibly asked for a meeting with the pathologist to help them understand why she had died. And that pathologist was evidently me.

  I was
saved by my colleagues, who did all the talking. I was simply not up to the task, so unbearable did I find the relatives’ shock and grief. In fact, I felt utterly helpless in the face of their emotion. Their misery seemed to transmit itself to me, to my mind and my body, as if we were attached by invisible wires. I don’t remember if I said anything at all: if I did, I probably just kept repeating how very sorry I was for their loss. Mostly I am sure I nodded while my colleagues talked.

  The meeting introduced me – or, perhaps no introduction was necessary – to the awful collision between the silent, unfeeling dead and immensity of feeling they generate in the living. I left the room with relief, making a mental note to avoid the bereaved at all costs and stick to the safe world inhabited by the dead, with its facts, its measurements, its certainties. In their universe, there was a complete absence of emotion. Not to mention its ugly sister, pain.

  7

  Even at thirty, I was much better at managing strong emotion than experiencing it. I suppose that in my boyhood I must have learned to work hard at suppressing the anxiety caused by my mother’s illness. And then at just carrying on, despite my grief at her loss. Our home, with its silences and spaces, became a sort of desert where, to my relief, strong emotion did not flourish. Although from time to time it would appear so suddenly through my brother’s challenges or my father’s vaporizing tempers that it seemed to be something very scary, dropped suddenly from another planet. It was certainly very hard to believe it had been there, beneath the surface, all along.

  I would have liked life to be emotionally uneventful but by the time I performed my first post-mortem that was certainly not the case. I returned home from the mortuary and opened the front door to hear the wails of my new baby son. He was oblivious to the extraordinarily powerful love and bewilderment he stirred in his parents. And as for my wife, she showed no sign of satisfaction with the flat emotional landscape I preferred.

  Jen and I had met at the hospital when I was a student. She was the beautiful, dark-haired nurse who mopped my brow during finals, who entered my life with a great vitality and whose cleverness I admired. Each day she finished most of the Times crossword at ridiculous speed – although not quite as quickly as her father, Austin, could finish the Telegraph’s. He had retired from a distinguished career in the Colonial Police in Uganda after seeing service in the Indian Mounted Police and was now living on the Isle of Man.

  Jen’s parents were the beating heart of Manx society. When she took me home for the first time I was overwhelmed by her dizzy, busy and, it seemed to me, luxurious world. Austin presided with great charm over a living room full of visitors. Whisky and sodas, noise and laughter, the great old house’s lack of physical warmth was unnoticeable for the warmth of the welcome there. The furniture and curtains were all swathes and swags. The immense, if slightly dilapidated, kitchen smelled good. And there were always two dogs asleep in front of the oven.

  It didn’t matter if we arrived late at night; Jen’s mother, Maggie, gin-and-tonic at a precarious angle in one hand, wooden spoon waving in the other, would greet us extravagantly and ply us with fine food. She was the sort of woman whose presence defined any party. The sort of parent my siblings assured me my own mother had once been, although I could hardly imagine such a thing. Viewed from the noisy whirl of Austin and Maggie’s home on the Isle of Man, the house of my upbringing seemed a sparse, silent place. Empty, even. I tried to remember with affection the radiogram, the antimacassars, the swirly carpet in my childhood home. And couldn’t.

  On our marriage, Jen’s kind parents helped us buy our new home in Surrey. I had qualified as a doctor, finished my ‘house’ jobs and was just about to start training as a pathologist. Jen was now working as a health visitor. We couldn’t, for a while, afford a proper bed or any furniture at all, but we were happy. Then, after a few years, we knew that the time was right to start a family.

  We were unaccustomed to adversity but here it came, making up for lost time. Jen had a miscarriage. We were both devastated. I had no idea how to deal with my overwhelming feelings of loss, my sense of the child that could have been, the life that might have been lived, nor what to do with the love that should have belonged to that baby. My pain was an enormous, invisible thing I carried awkwardly around. Where on earth was I to put it? This was so preoccupying that I was entirely incapable of offering Jen enough support in her own great sadness. Was I supposed to say something? Do something? If so, what?

  I failed to say it, whatever it was, I failed to do it, whatever it was, and I also failed to admit that I was completely out of my emotional depth. So, when we lost the next baby, then the next, I became more and more distressed by Jen’s apparently unassuageable grief. It was a true reflection of my own unexpressed devastation but, rather than look at it, I confess, with many regrets, that I turned my back. I became increasingly isolated. So did she.

  I did manage to tell her how much I loved her and how sad and confused I was that our babies could not seem to grow larger than a cluster of cells. Would that do?

  No. She seemed to expect more from me. And she was right. Although I still couldn’t imagine what I was supposed to offer. Just as, when a young boy, I didn’t really know what people had wanted me to do after my mother’s death.

  Finally, when she found she was carrying yet another baby, Jen was confined for almost the entire pregnancy to bed rest in hospital. It was not a happy time, separating and isolating us from each other still further. Until, at full-term, a beautiful boy, whom we named Christopher, was born one winter’s day.

  Most parents will remember the chaos of their first, longed-for arrival. I’d been overwhelmed because there was no baby. Now I was overwhelmed because there was a baby. And so was Jen, even though she was by now an experienced health visitor. As for me, I was a doctor with a stint in paediatrics behind me. But we were both taken aback by the weeping, the sheer dissatisfaction with which our little prince responded to our efforts to please him. And all the time we were awash with a love for him which was so deep and passionate it shook me to the core. And his apparent lack of appreciation of our efforts perhaps shocked us both.

  When I returned home after completing my first post-mortem and opened the door to Chris’s familiar, high-pitched wail and the sweet smell of baby oil, I found Jen upstairs. The busy mother of our tiny son was elbow-deep in baths and nappies, gently shushing the eternally protesting Chris. Downstairs, her books were propped open in the living room: she’d just started studying for an Open University degree but Chris and his yells had seen off that plan this evening.

  Every moment of Jen’s time was filled: no wonder she had forgotten it was such a big day for me. And now that the hurdle of my first post-mortem was receding into the distance, this racehorse began to wonder if the hurdle had really been so high anyway.

  I went upstairs to see them both. Chris looked at me and wrinkled his face into a ball from which a smile might have emerged. Or a roar of disapproval. Predictably, it was a roar. I took him from Jen and he wailed some more. I rocked him, swung him, gazed at him, pulled faces at him. His tiny features twisted themselves again into a comical but unbecoming ball. A smile? Of course not. Out came another huge wail. How, how to stop him?

  Jen put the baby to bed while I made the evening meal. Miraculously, Chris’s roars upstairs subsided just as the meal was ready downstairs. We ate it, relishing the silence as much as the food. After supper, we both studied. I was in a world of exams without end, a world Jen, on her degree course, was just entering.

  And now it’s late. I am exhausted, having spent much of last night worrying about and preparing for today’s post-mortem. The day is over and when my head hits the pillow I know all I want is sleep, sweet sleep. I can feel it engulfing me. My body relaxes happily, I am slipping downstream when suddenly … Waaaaah!

  Chris. Again. God, again. He cries so much that we’re starting to suspect that, despite being breast-fed, he might have a lactose intolerance. But what good are all the
theories in the world going to do me now? Because Chris may be allergic to milk but he has excellent lungs and he is crying and one of us will have to do something.

  ‘Your turn,’ mumbles Jen.

  I get up. The house is still and cold.

  I reach into the cot and scoop up Chris’s hot, stiff, angry little body. I love him but I want to go back to sleep. I walk around the house, cradling him in my arms. Lack of sleep is depriving me of my humanity, I am a robot doomed to walk until the end of time with my kicking little bundle. I know the bundle is a baby, a vulnerable baby. But I am beginning to wonder. Is he, in fact, a tyrant? A tyrant whose sole and monstrous aim it is to deprive me of what I crave most, sweet sleep?

  Gradually, after a long, long time, gentle rocking persuades him to cry less, to yawn more, to close his eyes. I listen to his breathing. Even. Deep. Yes, he is asleep.

  Very, very gently, stealthily, like an art thief, I traipse to the nursery and place my tiny masterpiece oh so gently into his cot. I pull the blankets over his sweet-smelling body. He is pliable now with drowsiness. I watch him for a moment. He pulls a face and that may mean … I hold my breath but all remains silent. He is dreaming. I feel something similar to joy as I creep towards our bed. The duvet closes over me like an embrace, I shut my eyes. And then … Waaaaaah!

  What desperate parent hasn’t feared that he might shake the baby or lose his temper and chuck the baby into the cot, or give the baby a short, sharp slap to stop the noise? What desperate parent hasn’t been terrified by his own pressing need for respite from the constant demands, the wearing, piercing Waaaaah?

  I knew that, although Chris was distressed, he was safe enough. I knew I needed a few quiet moments. I shut the bedroom door on my crying son and went downstairs into the kitchen. I shut this door behind me too. He was still crying but the crying was distant. I covered my ears. I could no longer hear him. I continued to cover my ears for five minutes. Breathing deeply. Regaining my equilibrium. Then I returned to his cot. Maybe not full to the brim with love, but certainly lovingly, and with my compassion rekindled. I rocked him gently back to sleep.