This industrial-strength wrapping was necessary to keep a variety of things inside the bag and away from the other patients in the same fridge: smells, fluids, maggots, flies, snips, snails, puppy dog tails … all the things that a decomp is made of.
I had a deal with June that she would carry out autopsies on all the bariatric bodies (which is the politically correct term for ‘obese’) if I did all the decomps. She was only too happy to oblige, although she couldn’t understand my choice. ‘Why? Why would you want that? What goes on in that head of yours, Tiny?’ She called me Tiny because I was still hitting the gym hard and was very slim at the time – something that caused me some difficulty with the larger bodies. I explained this fear to her – the fear that I might fall into the body cavity, my legs comically poking out and flailing around.
Most APTs hate decomps with a passion but I didn’t mind them; after all, I was a veteran due to my childhood spent directing funerals for roadkill. I found the decomposing deceased intriguing, and quickly became immune to the moist, squelchy noises, fetid smells and endless parade of insects. All these colonising creatures fascinated me, as did the topic of Forensic Entomology, which I’d studied at university, so I often collected maggots and other insects from autopsies in white-lidded Sterilin pots and conveyed them down the road to the World Museum, Liverpool, during my lunch break. I could happily chat to an entomologist about what species it was at the same time as eating my sandwich. They were always just the usual larvae and flies you’d expect to find in the UK – blowflies, cheese skippers, bluebottles – but I liked being there, talking entomology and looking through the myriad drawers of insects pinned down in their little white death-beds. The staff even came to know me as ‘Maggot Girl’ – a term of endearment, I assumed, although very descriptive of me in general: you see, I often needed to remove maggots from my clothing during autopsies, and once even from my bra.
It was unusual.
The maggots themselves weren’t unusual, just the fact that they had managed to access my bra. Maggots are a weekly occurrence in some mortuaries and can be practically a daily one during the summer months. It’s an unfortunate fact of life that many people, by choice or circumstance, die alone and aren’t discovered for a long time. (Take the incredibly sad, albeit exceptional, case of Joyce Carol Vincent, found dead at home in 2006, although it was believed she had died in 2003. The TV was still on after three years.) This means that their cadavers become fair game for scavenging creatures either as a place to inhabit, a food source, or both.
Normally during a particularly messy autopsy I’d be wearing full PPE which includes a green cotton surgical gown over my scrubs.* As this isn’t waterproof and is liable to soak up any errant fluids I could inadvertently lean into, a disposable plastic apron goes over that. A similar principle lies behind the use of white plastic sleeve protectors, because even though latex gloves cover the hands, they will only pull up as far as your wrists. The disposable sleeve protectors – elasticated at both ends and similar to futuristic shiny legwarmers – shield the absorbent gown sleeves from a possible creeping wave of blood and fluids which may silently ascend to the elbow. And it wasn’t just the one pair of latex gloves I’d wear but two, with ‘cut proof’ fabric gloves worn between the layers like a safety sandwich. This is imperative to ward against possible scalpel or needle-stick injuries which are a daily danger during autopsies. We call these ‘cut proof’ fabric gloves ‘chainmail’ because they’re woven through with an incredibly fine metal mesh to stop an errant blade from slicing through to the skin. However, the threads have to be relatively wide apart to allow for manual dexterity, which means that needle points, and even the tip of a scalpel, can sometimes prick through between them. This is where the extra latex comes in: the two layers ‘wipe’ away blood and debris at a microscopic level as the sharp metal penetrates, so even if it pierces skin there is marginally less chance of catching something. When it comes to trying not to catch communicable diseases, every little helps.
Add to this ensemble a hair net and plastic face visor which steams up with every breath, and you can imagine how hot and sweaty it can get carrying out an autopsy in the summer, and how ‘glamorous’ it looks.
This is why a maggot got into my bra: it was seriously sweltering in the tiny post-mortem room that day. The air-conditioning wasn’t working, and not for the first time. More importantly, neither was the downdraft system which is specifically meant to force any airborne pathogens away from our faces and down to the floor where they can wreak less havoc. I’d decided to forgo the cotton gown and instead wear a plastic apron directly against my scrubs, and the plastic sleeve protectors against the skin of my arms. It seemed smarter than wearing the cotton gown as well and fainting with heat exhaustion halfway through the procedure, perhaps cracking my head on the corner of the PM table on my journey down.
I was between a rock and a hard place here.
However, I could still feel the suffocating effect of the plastic on my flesh as beads of sweat, with nowhere to go inside their impermeable prisons, simply rolled up and down, up and down, as my arms changed position. I also couldn’t see through the visor which kept steaming up from the heat of my face, so I removed that too. Without a visor or surgical mask I did feel slightly more comfortable, but, wearing a hair net and holding a ladle to remove liquid fat and blood from the cavity, I looked like a demonic dinner lady.
‘How are you doing over there, Tiny?’ June called to me, a look of bemused humour on her face. She always thought I’d regret my decision to take the decomps, but I never did.
‘I’m fine, I’ve got it. It’s not so bad,’ I responded, but then I felt something cold and wriggly drop through the ‘V’ of my scrubs top. With no gown to protect my décolletage I was wide open to this invasion. By the time the maggot had landed skilfully between the fabric of my bra and my breast I had dropped my PM40* and was frantically shaking the front of my scrubs and hopping from one foot to the other until I’d secured its release and it landed on the PM room floor. It was only then I realised June was doubled over with laughter – she’d seen it on my shoulder and had predicted the outcome without warning me. I plotted a way to get her back, and soon.
* * *
Putrefying cadavers teeming with scavengers are an ecosystem unto themselves. I don’t really believe in literal reincarnation – that a person’s mind and soul remain intact and inhabit different bodies or vessels over time – but looking at the activity of new-born larvae and scuttling beetles as they devoured decomposing flesh gave me an understanding of what the ‘circle of life’ really meant, and it was nothing to do with cartoon lions and cheesy Elton John songs. The First Law of Thermodynamics states that energy cannot be created or destroyed, it can only change form. This means that though the force can flow from one place to another, the total energy of an isolated system does not change. If we consider the Earth and all its flora and fauna an isolated system, then the vital force of all those who pass away must in turn animate the insects who feed on them or leach into the soil in which they are buried. The fruit and vegetables that feed us, as well as feeding the animals we eat, grow in that soil and in that way the energy is ‘reincarnated’ or changes form. Edvard Munch put it succinctly: ‘From my rotting body, flowers shall grow and I am in them and that is eternity.’
But why is the decomposing cadaver such an ecosystem, or biome? It’s necessary to explore the processes of decay in detail to establish why something seemingly so revolting sustains millions of creatures, and understand that without those creatures we’d be knee deep in corpses. If you’re the kind of person who can’t watch gruesome horror scenes in films, or jumps when a spider or rat appears, then you might want to skip this next section …
* * *
Decay starts when the heart stops, although of course many would argue that the Placebo song ‘Teenage Angst’ is more accurate with its lyric ‘since I was born I started to decay’. However, for our purposes decomposition, often split
into five stages – fresh, bloat, active decay, advanced decay and dry remains – begins immediately after death. We’ll begin with ‘fresh’ – and I discovered early on that ‘fresh’ is a very relative term when associated with corpses. It doesn’t mean fresh like fresh air; more fresh as in a freshly soiled nappy or fresh sewage; fresh as in ‘OK, you’re not going to want to put your face in this, but believe me, it could be way worse’.
Fresh
During this stage, one of the most well-known indicators of death, post-mortem rigidity or rigor mortis, begins between one and four hours after death. It occurs because several proteins in the muscles, which ‘join hands’ to create movement in life, are unable to let go since the substance that would enable them to do so, adenosine triphosphate, isn’t being formed any more. Rigor starts in smaller muscles such as those found in the eyelids, jaw, neck and fingers. Some of these small muscles are in the iris, which is why a test for death is to shine light into the eye: dead pupils won’t react to the light by constricting. Others affected are the arrector pili, tiny muscles that move the hair of mammals, for example, to create goosebumps; it’s this action, their making the hairs stand on end, which gave rise to the fallacy that the hair grows after death.* Between four and six hours after death, larger muscles are affected by rigor and the first stage of flaccidity (primary flaccidity) is over as the body becomes stiff and immobile. Rigor takes such hold of the limbs that attempting to move them into a different position can actually break the joints. I’ve heard the loud crack of this myself, although I’ve never been strong enough actually to break rigor, and I’ve never had reason to.
Most of the cases I’ve autopsied have been in one stage of rigor or another, and sometimes this can hinder the examination. For example, during the external exam, the pathologist must examine the genitalia and anus – it’s part of a sequenced process that is the same for every single body so that nothing is missed. In some women’s cases the pathologist and I have had to take a stiff leg each and heave them apart slowly, like pulling giant levers, to gain access. It’s not dignified, no, but the checks are done in every autopsy so the pathologist can report any disease or ensure there’s been no sexual violation. If there has been and it’s not detected, it could mean the perpetrator walking free.
Much of what happens in a post-mortem examination may look undignified, but it’s all an essential part of the process. Even so, there are times when I’ve been over-sensitive and the touch or actions of a pathologist have alarmed me. In one case, I remember a homeless pregnant girl, only fifteen years old, had committed suicide by jumping from a building. Her last known address was a care home and she had a severe drugs problem. Suicide, drugs, pregnancy and homelessness: all this at just fifteen. The pathologist I was with on the case had a group of medical students in the room with us and I understood they were there to learn. She had genital warts, the teenager, and when the doctor noticed and asked me to help spread her legs, which were in rigor, to show the students I just snapped and screamed ‘No!’ I couldn’t help but think about how this girl had already been failed so many times, had probably been unable to protect herself, had likely suffered many indignities and violations. I couldn’t let her suffer yet another; I couldn’t just allow all these students to peer at her private parts like she was some specimen when they could easily see genital warts on a consenting live patient. They weren’t pertinent to this case. The pathologist looked at me and didn’t say anything about my outburst. I think he could tell by the look in my eyes that it was just unnecessary this time.
* * *
Around the time the body has fully succumbed to rigor mortis, another indicator of death becomes more obvious. This is hypostasis, also called lividity or livor mortis (both Latin for ‘purple’ or ‘bluish’). The reason we say someone is livid when they’re angry is because their face goes purple. Lividity is a purpley-pink staining of the skin caused when the blood stops flowing and sinks downwards due to gravity. This means it settles or pools in the vessels at the points lowest down, except in those parts that are in contact with something, because those vessels are constricted or pressed closed. So if a person died lying on her back, for example, her upper back and shoulder blades would be white where they were in contact with the bed. Her buttocks, calves and heels would also remain white, or blanched. Any tight clothing, like bra straps, could cause blanching too. Sometimes in cases I worked on this was so clear that I could read the impression of the brand name around people’s waists: Calvin Klein or Superdry.
At around ten hours this discolouration becomes very prominent, and can become what is known as ‘fixed’ after about twelve – this means the difference in skin tone, dark lividity and paler blanching, will not change back. It’s a variable process so isn’t always a good indicator of exact time of death, but if a cadaver is moved before fixation – say, from a chair to a bed – a second pattern will form and investigators can use this to indicate if someone is lying about how that body was found. In my experience, all sorts of things make patterns in the skin, and can reveal a lot about the death scene. Hypostasis happens whatever position the deceased is in so a person who hanged himself will have a much paler torso but his legs will be so full of blood they’ll turn dark purple. This is called ‘congestion’. Congestion is one of the reasons it may seem like a hanged man has died with an erection, but in reality the pooling blood is just flowing into every nook or cranny it can due to gravity.
It’s very important that a pathologist and an APT can distinguish between hypostasis and bruising during the external examination, as genuine bruises may indicate the circumstances which led to someone’s death. They can have very particular patterns which help to give us information. For example, bruised shins are common in alcoholics who frequently stumble around and bang into their furniture at home. Taken with other evidence such as liver disease and the sickly sweet smell of alcohol in the blood (another reason we don’t shove menthol up our noses), we begin to tease out the story of how the decedent passed away.
During one of our cases – a lady who was a known alcoholic – the pathologist became suspicious of a set of bruises on the woman’s upper arm.
‘What do these look like to you?’ he asked me.
‘Finger marks,’ I replied, corroborating his thoughts.
There was a distinct set of four elliptical bruises in a line down her tricep, as though someone had grabbed her upper arm with their hand. Taken with all the other injuries on her, it now looked like she could have been beaten rather than just stumbled around and injured herself. At the same time, there was marked hypostasis changing the colour of huge portions of her skin. The pathologist decided it was better to be safe than sorry and halted the Coronial post-mortem to refer it back to the Coroner, who would have to order a forensic post-mortem. We had to be absolutely sure that this woman hadn’t been a victim of manslaughter or murder and a forensic PM is a different procedure, usually carried out by a different doctor, one trained not just in pathology but forensic pathology.
Another pet peeve here: forensic comes from the Latin forensis which means ‘before the forum’, such as a jury. It means something pertaining to the law. So on TV when a documentary says, for example, an Egyptian mummy is going to be ‘forensically examined’, it’s not … unless the mummy is a victim of crime or stands accused of a crime.* What they are using are analytical techniques which are sometimes applied forensically, in a criminal case. Forensic PMs require completely different staff to be in attendance: investigating police officers as well as exhibits officers and a photographer, in case the evidence needs to be presented in court. That’s why a routine Coronial PM can’t just become a forensic one – it’s a whole different procedure. New paperwork has to be started from scratch and often a new venue and pathologist found.
* * *
The deceased is also by now quite cold, having succumbed to another indicator of death: algor mortis, or post-mortem cooling. A sweeping generalisation is that the dead body loses
2ºC in the first hour after death then 1ºC per hour thereafter, until ambient temperature is reached. Again, there are many factors that may affect this, such as a fever, which would give someone a higher temperature at death and delay cooling. For the most part, the autopsies I’ve carried out have been on cold flesh, which is also relatively stiff because the deceased will have been in the mortuary fridge and human fat, just like butter, solidifies as it cools. But on the odd occasion a patient may come down from the wards and require an immediate PM – while still warm. Some people who work with the dead hate this as it’s just too human; too real. It feels more like surgery and less like an autopsy. I never minded the warmth. Despite all those layers of gloves I was sensitive to the cold and it would make my fingers stiff, so the warmth was a bit of a relief for me. (Being a mortician has some odd perks, but you take them where you can get them.)
Between thirty-six and forty-eight hours after death, those ‘hand-holding’ proteins which caused rigidity have started to degrade, so rigor mortis finally loses its grip. This leads to secondary flaccidity, and the body won’t stiffen again. The reason these proteins have degraded is that decomposition proper has started to become noticeable, and this can be split into two distinct pathways: autolysis and putrefaction.
The Chick and the Dead Page 8