Although generally any violent or unnatural death merits a trip to the autopsy room, families do have a right to object, particularly on religious grounds; we, in turn, have an obligation to attempt to accommodate their wishes when we can. Sometimes that is possible. In situations where the law does not mandate an autopsy, we can usually work it out with a family—for instance, if the case of suicide is very clear, from notes left behind and other clues, and if the family does not want an autopsy, we may be able to make our findings without putting a knife to the body. In addition, advances in technology have created more and more noninvasive procedures like CT and MRI scans that sometimes yield enough information on which to base a finding without having to autopsy.
Often a family that resists an autopsy will ask me a version of this question: “They put a man on the moon, and you’re telling me that with all the technology that’s available today, you still have to cut him up?” Essentially the family is demanding to know why we are not using a CT scan or MRI to find out what has gone on inside the body of their loved one, instead of doing a traditional autopsy. This is a very good question, and the old answer to it—because noninvasive means aren’t precise enough to tell us what happened to the decedent—is changing.
In clinical medicine, the general purpose of CT and MRI scans is to limit the need for invasive diagnostic procedures, since the less you physically poke around inside someone, the greater his or her chance of getting out of the hospital alive and in one piece. Traditionally this concern was considered a nonissue once the patient was dead. After all, what harm can poking around do to a dead person? While at present even the very best imaging procedures available cannot rival the wealth of information that a skilled physician can gather by going inside the body, in the not-too-distant future, the balance between the information we can discover from actual samples and what we can obtain through noninvasive procedures may shift in favor of the latter. The grail for ME’s offices might then be a virtual postmortem that could potentially yield equivalent, if not more, information than an actual autopsy, while sparing families from having their loved one undergo an autopsy that perhaps runs counter to their religious principles.
This would be especially useful when dealing with those autopsies that we are required by law to perform, regardless of objections. The following unfortunates receive automatic trips to the autopsy table: homicides, people whose deaths may involve threats to public health (such as outbreaks of plague, anthrax, or Legionnaires’ disease), and prisoners. A prisoner, by the way, is defined as anyone incarcerated in a prison, remanded to a mental institution, or even just detained by the police at the time of death. Although the law absolutely mandates an autopsy in these cases, if the family objects, particularly on religious grounds, there are steps that we can take to ease their trauma. For example, some Buddhist sects do not permit the remains of the faithful to be refrigerated, so we try to autopsy those bodies quickly and release the remains to the family on the same day.
Similarly, special steps need to be observed when dealing with members of the Jewish population that require autopsy. Jewish tradition forbids autopsy and, further complicating things, demands that any blood spilled before or after death be interred with the body. Moreover, the burial must take place within twenty-four hours of death, and until the burial, a member of the faith must attend the body at all times. Given New York City’s large Jewish population, the OCME quickly became expert in what we called the “rabbinical autopsy.” When faced with a mandated autopsy on a Jewish decedent, a well-rehearsed routine would commence at OCME. Rabbis from various Jewish funeral homes would arrive and sit with the body until it was autopsied. The autopsy would be conducted as usual except that the entire procedure would be done with the body inside a waterproof body bag. This way, any blood leaking out of the body during the autopsy would be caught by the bag, which would then be buried with the body. At least one rabbi would attend the autopsy and supervise the collection of bloody paper towels or anything else produced during the autopsy that might have to be buried with the remains. The body would usually be removed to the funeral home by the rabbis immediately following the autopsy.
The willingness of OCME to go the extra mile to accommodate a family is not limited to highly religious Jews or to any particular sect or religious group. Any reasonable request by a family member is met with the utmost sensitivity, and every attempt is made to accommodate that family member’s wishes.
Interestingly enough, the rationale for performing a mandatory autopsy on every homicide victim stems from the famous death of a rabbi. In 1990, Rabbi Meir Kahane, the founder of the Jewish Defense League, was murdered in New York, but because of religious objections from his militant religious followers, his body was not fully autopsied. Instead, a limited autopsy, a “bullet-ectomy,” was done and most of the normal autopsy was foregone.
During the murder trial that followed, the defense attorney for El Sayyid Nosair, the man on trial for killing Kahane, accused the NYPD and OCME of a cover-up and of framing his client. On cross-examination this attorney tarred and feathered the ME personnel who testified for our office, primarily because a full autopsy had not been done. While there had been no conspiracy to frame anyone, the fact that a full autopsy was not done looked bad. After this case, the rule was firmed up: every single homicide would be autopsied, regardless of whether we’d learn anything from that autopsy, and regardless of familial or religious objections.
At the OCME, we begin autopsies at 8:00 A.M. and stop them only once the cases for the day are completed, which is usually by 12:00 P.M. A basic autopsy takes about an hour. “Any longer,” quips Dr. Hirsch, “and you’re not practicing medicine, you’re holding services.”
The whole process begins when you enter a brightly lit room that is surprisingly noisy, what with the sounds of saws, bolt cutters, doctors talking, and water running. In addition to the noise, it is also surprisingly hectic, since generally three or four autopsies are going on at the same time. There are eight autopsy tables laid out in a row, facing the sinks that line one fifty-foot wall of the rectangular room. On my first day, my training officer pointed the sinks out, telling me, “If you’re gonna throw up, do it in the sink, not on the body. And also, take your mask off first or you’ll drown.” Indeed, it was advice worth heeding.
As you approach the first table, you see that the body is intact and laid out, naked and face up. While you were gowning up outside, its clothes were removed and external photographs were taken. The body was weighed and measured for height. With those logistics out of the way, the ME now notes any remarkable external features, such as deformities, amputations, lesions, trauma, tattoos, and the like. Careful attention is paid during the preliminary external survey to the eyes and inner eyelids for signs of petechiae, small spots of hemorrhage that can be an indication of trauma caused by strangulation or compression. The mouth is also carefully examined for the presence of lacerations to the inner lips, broken teeth, or any other subtle indications of trauma.
After the external exam is accomplished, the ME, taking up a position on the decedent’s right side, grabs a scalpel and begins the internal examination. He makes a deep Y-shaped incision across the entire trunk: from the left and right collarbones down on two diagonals to the top of the sternum or breastbone, and then straight down the center line of the chest and abdomen all the way to the pubis bone. Then he peels back the skin and underlying muscles from this incision—we use the word reflected to describe this action. That exposes the ribcage protecting the heart and lungs, and the abdominal viscera (organs and guts), which are covered by the omentum, a fatty apron of connective tissue. Putting down the scalpel, the ME picks up a long bolt-cutter, the kind police use to snap locks. With this tool, he snips the ribs along the sides of the body, one by one, until he frees the entire front breastplate, ribs, and sternum. Then he lifts out and sets aside the ribs/sternum combination as a connected series of bones. The heart and lungs are thus exposed. The omentum is pus
hed aside, revealing the abdominal viscera.
Scalpel back in hand and reaching in with gloved hands, the ME then cuts out each organ and individually weighs, examines, and dissects it. The weighing is very important—one of the best ways to tell right off the bat if there is something wrong with an organ is if it weighs too much or too little. A normal, nondiseased adult heart, for example, weighs in at between 300 and 500 grams (about half a pound), depending on the size of the person in whom it used to beat. Certain diseases, such as high blood pressure, can cause the heart to grow dramatically larger, and this pathologic condition, called cardiomegaly, can kill you.
A famous case of cardiomegaly was found in the heart of André Rene Roussimoff, better known as André the Giant, a French-born American wrestler and actor. Roussimoff actually suffered from acromegaly, or gigantism. At the time of his death, he was close to seven feet tall and weighed over 500 pounds, and his heart reportedly weighed an amazing twelve pounds.
After the ME is done examining the heart, which includes cutting into the coronary arteries to look for plaque, and checking out the valves and chambers, he attends to the other organs. The healthy liver is a huge, red-brown, floppy thing that looks exactly like the raw calf ’s liver your mother might have brought home from the butcher when you were a kid. On the other hand, a diseased liver, like a cirrhotic or fatty liver that we find in alcoholics, or in ducks that are force-fed to produce foie gras, is often smaller than normal, yellowish, and stiff. You can spot an alcoholic’s liver from across the autopsy room. Similarly, a smoker’s lungs look drastically different from normal lungs. Dedicated smokers develop sooty deposits in their lungs that can turn lung tissue from a normal pinkish–blue-gray color to very black; in advanced cases, the lungs can become stiff and even develop large holes.
The stomach is filleted open, and the contents, if any, are examined. When I first began attending autopsies, I was disappointed that stomach contents were usually a tan- or gray-colored mush. From innumerable television crime shows, I had expected to see some easily recognizable remnants of the decedent’s last meal. While some residue is occasionally visible, particularly from fibrous foods like broccoli or corn that remain more or less intact in the stomach for a long time, most often what we find in terms of stomach contents is no more than well-macerated mush.
Continuing down the digestive tract, the ME next “runs the bowel.” A loop of intestines is grabbed near the point that the intestine joins the stomach, and the loop is punctured. An open scissors is inserted into the puncture point, and the bowel is pulled back against the scissors until it is entirely cut open, down to the rectum. This is, as you can imagine, a particularly smelly part of the autopsy. Not surprisingly, many MEs have their morgue assistants do the actual opening of the intestines, and they wait to examine the bowel until it has been washed.
Once the abdomen is done, it’s on to the pelvis and its organs. During the autopsy of either sex, the rectum and anal sphincter are examined and the bladder is removed and studied. In males the scrotal sac is opened and the testes removed and sectioned. The penis is examined and the urethra (the tube running down its center, through which urine and semen travel) is swabbed. This swabbing can produce evidence of recent sexual activity or the presence of sexually transmitted disease (STD).
As with males, in females the examination of the genitalia and pelvic organs can reveal evidence of recent sexual activity, help us to differentiate between forced and consensual sex, and detect the presence of STDs. In women, the autopsy can also reveal if the decedent had ever borne children and if so, approximately when. During the autopsy, the ovaries, fallopian tubes, and uterus are removed, examined, and sectioned. The vaginal vault is examined, as are the external genitalia. If sexual assault is suspected, a so-called rape kit is used to swab (separately) the vagina, anus, and mouth with long cotton tipped applicators; any collected evidence is sent to the lab. If the decedent was raped as well as murdered, careful preservation of DNA evidence is of paramount importance, because in few other types of homicides do perpetrators leave such a clear calling card.
Throughout the autopsy, removed organs are sectioned, or to put it in layman’s terms, “sliced up,” on a cutting board, similar to the ones used in most kitchens. Small sections of every organ are carefully snipped off and placed in stock jars that are then sent to a storage room, where they are kept for at least ten years.
Samples of the blood, bile, urine, stomach contents, liver, brain, and anything else that the ME thinks appropriate to assay are sent to the toxicology lab to be tested for drugs and poisons. Often the ME will also elect to send vitreous humor—commonly known in the autopsy room as “eyeball juice”—to the tox lab. A long needle on a large syringe is pushed into the corner of each eyeball in turn, and all of the fluid is sucked out. This deflates the eyeballs. Sunken eyeballs would look terrible in an open casket, so the eyes are then refloated by injecting saline solution into them until they are once again nice and plump.
After the ME has finished examining the insides, the body lies on the table, empty of all of its organs; in the parlance of the autopsy room, it is a “canoe.” The physician stuffs what remains of the viscera into a black garbage bag, and inserts the bag into the abdominal and chest cavity of the corpse, refilling the canoe. If necessary, the ME will then cut open and examine the insides of the four extremities. Most of the time, this is not done because the organs will have provided enough information on the cause of death.
The neck is then dissected and the tongue is pulled down and out through the hole under the neck and examined. (When drug dealers do this to an informant after they kill him, they call their procedure a “Colombian necktie.”) As most mystery-novel readers know, at this point in the autopsy, careful attention is paid to the delicate “strap” muscles of the neck, and to the tiny hyoid bone that overlies the windpipe, especially in a case where strangulation is suspected.
Moving up to the brain, the ME makes an ear-to-ear incision in the scalp, at the level of the eyebrows but in the back of the head. Then he or she pulls the scalp forward—clean off the skull bone—over the eyes and face, down to the chin. Putting aside the scalpel, the ME takes up a whirring saw and uses it to cut off the top of the skull. The pate doesn’t come off easily, so the ME will exchange the whirling saw for a sort of small chisel and use it to go around at the cut mark, prying up the skullcap. When the cap finally comes apart from the rest of the skull, there is a sucking sound like none other I have ever heard.
Now the ME takes up the scalpel again and goes around with it inside the cavity, using one hand to support the brain while the other (with the scalpel) severs the connective material that holds the brain in place within the skull. Once the brain is cut from its attachment to the spinal cord, it is ready to be lifted out. It is surprisingly gelatinous—like a soft-boiled egg—and to be properly examined, it must first be removed and hardened. The ME scoops the brain in gloved hands and drops it gently into a bucket of formalin, a pickling solution containing formaldehyde. The brain will then sit in the neuropathology room for the duration of the hardening process—making it into a hard-boiled egg—which will take about two weeks. After that, the brain can be sectioned, cut into small equal slices like bread in a bakery machine, and examined. If appropriate, small samples can be more minutely examined under a microscope. In our “Brain Room,” there are shelves of white buckets containing human brains, and yes, one white bucket is labeled “Abby Normal.”
After the brain has been removed and placed into the formalin, the autopsy is officially over. The ME calls for a morgue attendant who sews up the body cavity, using a large curved needle and heavy waxed twine. Wadding is stuffed into the skull where the brain used to be, the skullcap is replaced, and, using the same needle and twine, the scalp is sewn back on. The cutting has been done with precision and some delicacy, so that if a family desires it, the autopsied body can later lie in an open casket and not appear to have been cut into at all. Judicious plac
ement of the head on a pillow will conceal the incision at the hairline in the back of the neck, and the other cuts can be hidden by clothing.
As mentioned earlier, the autopsy of an adult body, from opening to closing, generally takes under an hour. The exceptions to this rule are the complicated homicides, particularly multiple gunshot wounds because ascertaining the bullet paths and trajectories by means of long metal probes can be a tedious and time-consuming task.
I have heard MEs grouse when they are assigned a multiple gunshot wound case; the axiom is, “I would rather autopsy five bodies, each with a single gunshot, than one body with five wounds.” It’s not that the ME prefers mass murder, but rather that a multiple gunshot case can be incredibly complicated. Each bullet must be marked to ascertain its path through the body and direction of travel; entry and exit wounds must be identified. Every step must be fully documented, so that the procedure will be able to withstand blistering scrutiny from the defense, should the case be brought to trial. Often, the most crucial testimony offered by MEs involves the direction in which bullets were traveling—for example, in a “police shooting” case in which other witnesses contend that the decedent was shot in the back by police. It is crucial that the autopsy be able to confirm or refute the eyewitness testimony.
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