by Sue Black
Working every day with death as my companion, I have come to respect her. She gives me no cause to fear her presence or her work. I think I understand her reasonably well because we choose to communicate in direct, plain and simple language. It is when she has done her job that I am permitted to do mine and, thanks to her, I have enjoyed a long, productive and interesting career.
This book is not a traditional treatise on death. It does not follow the well-trodden path of examining lofty academic theories or quirky cultural variations or offer warm platitudes. Instead I will simply try to explore the many faces of death as I have come to know them, the perspectives she has shown me and the one she will ultimately reveal to me some time in the next thirty years or so, if she chooses to spare me that long. And it is, like forensic anthropology itself, which seeks to reconstruct through death the story of the life lived, as much about life as about death – those inseparable parts of the continuous whole.
In return, I ask only one thing of you: suspend your preconceptions of death for a moment, any sense of distrust, fear and loathing, and perhaps you will begin to see her as I do. You may even begin to warm to her company, get to know her a little better and cease to be afraid of her. In my experience, engaging with her is both compelling and fascinating, and never dull, but she is complex and sometimes wonderfully unpredictable. You have nothing to lose – and in your own encounters with her, surely it is better to be dealing with the devil you know.
CHAPTER 1
Silent teachers
‘Mortui vivos docent’ (The dead teach the living)
Origin unknown
An articulated adult human skeleton which hangs in my laboratory.
FROM THE AGE of twelve, I spent every Saturday and all my school holidays for five years up to my elbows in muscle, bone, blood and viscera. My parents had a fearsome Presbyterian work ethic and I was expected to get myself a part-time job and start earning some money as soon as I was old enough. So I went to work at the butcher’s shop at Balnafettack Farm on the outskirts of Inverness. It was my first and only job as a schoolgirl and I loved every single minute of it. I was utterly oblivious of the fact that most of my friends, who preferred to work in pharmacies, supermarkets or clothes shops, considered it an odd choice, not to say vaguely distasteful. In those days I had no inkling that the world of forensic science was waiting for me but, looking back now, I see this as part of the pattern for my life that was hidden from me, and from them, at the time.
A butcher’s shop was an extremely useful training ground for a future anatomist and forensic anthropologist and a happy and fascinating place to work. I loved the clinical precision involved in the butcher’s craft. I learned a multitude of skills: how to make mince, how to link sausages and, most importantly, how to make regular cups of tea for the butchers. I learned the value of a sharpened blade as I watched them manoeuvre their knives swiftly and skilfully around irregularly shaped bones, paring away the dark red muscle to reveal the startling clean white skeleton beneath. They always knew exactly where to cut so that the meat could be rolled artistically into brisket or sliced evenly into stewing steak. There was something reassuring about the certainty that the anatomy they encountered would be the same every time. Or almost every time: I do remember the odd occasion when a butcher would curse under his breath about something not being ‘quite right’. It seems cows and sheep have their anatomical variations, just like humans.
I learned about tendons and why we cut them out; where, in the space between muscles, there are blood vessels that need to be excised; how to remove the confluence of structures at the hilum of the kidney (too tough to eat) and how to open the joint between two bones to reveal the glassy, viscous fluid of the synovial joint space. I learned that when your hands are cold – and they always seem to be cold in a butcher’s shop – you look forward to the delivery of fresh livers, still warm from the abattoir. For a fleeting moment, when you dipped your hands into the box, you could feel them again, thanks to the warm cow’s blood de-icing your own.
I learned not to bite my fingernails, never to place a knife on the block with the blade facing upwards and that blunt knives cause more accidents than sharp ones – although sharp blades leave a much more spectacular mess when a mistake is made. I still find it tremendously satisfying to see the neat array of anatomy on display in a butcher’s shop, always laid out precisely, cut and prepared the way it should be, and to catch that slight whiff of iron in the air.
I was sad when I had to give up the job. I idolised my biology teacher, Dr Archie Fraser, to such extent that whatever he said I should do, I did it. So when he told me I must go to university, off to university I went. As I had no idea what I ought to study, following in his footsteps and opting for biology seemed a good idea. I spent my first two years at the University of Aberdeen in a bored haze of psychology, chemistry, soil science, zoology (which I failed first time round), general biology, histology and botany. At the end of it all I found I was best at botany and histology, but the prospect of studying plants for the rest of my life made my eyes bleed. That left histology, the study of human cells. Having completed the histology module, I felt I never wanted to have to look down a microscope again – everything seemed to consist of amorphous blobs of pink and purple. It was, though, my route into anatomy, where I would be able to dissect a human cadaver. I was only nineteen and had never seen a dead body before, but for a girl who had spent five years of her life cutting up animals in a butcher’s shop, how hard could it be?
Perhaps my Saturday job prepared me in a very minor way for what lay ahead. The first experience of a dissecting room is, though, daunting for everyone. It is one of those moments nobody forgets because it assaults every single sense. There were only four of us in the class and I can still hear the echoes that reverberated round that vast, grand room which, with its high, opaque glass windows and intricate Victorian parquet floor, might have served in different circumstances as a conservatory. I can still smell the formalin, a chemical stench so thick you could taste it, and see the heavy glass and metal dissecting tables with their peeling green paint – forty or more of them, set out in regimented rows and shrouded in white sheets. On two of the tables, hidden under their sheets, were the bodies that were waiting for us, one for each pair of students.
It is also an experience that immediately challenges your perceptions of yourself and others. You feel very small and insignificant when it dawns on you that here is someone who, in life, made the choice to give themselves in death to allow others to learn. It is a noble deed that has never lost its poignancy for me. If ever I lose sight of the miracle of that gift, it will be time to hang up my scalpel and do something else.
At random, my dissection partner, Graham, and I had been assigned the cadaver of this selfless donor – a body expertly prepared for us by the anatomy technician that would be our world of investigation for a full academic year. Not knowing his real name, we rather unoriginally called him Henry, after Henry Gray, author of Gray’s Anatomy, the text that would come to dominate my life. Henry, a man who hailed from the Aberdeen area and was in his late seventies when he died, had elected to bequeath his body to the anatomy department at the university for the purposes of education and research. My education, and Graham’s, as it turned out.
It was sobering to think that at the time Henry had made his decision, I, his future pupil, was completely unaware of the amazingly generous act that would shape my entire life. I would have been busy bemoaning my lot of having to dissect rats in zoology, which I loathed.
When he died, I was probably cutting up another of the university’s apparently endless supply of plant stems to study their cellular structure, oblivious of his passing. Every year, when I talk to my first-and second-year students preparing to go into anatomy dissection in their third year, I tell them that the person they will study with, and learn from, is currently still alive. Perhaps that very day someone will be making the decision to bequeath his or her remains for the ben
efit of their education. I am always reassured when there are a few sharp intakes of breath as the enormity of that concept sinks in. There are inevitably a few who well up at the idea of a person they might have walked past on the street that morning ending up on their dissection table – and so they should. Such a huge gesture by a total stranger should never be taken for granted.
Henry’s cause of death was registered as myocardial infarction (heart attack) and his body had been collected from the hospital where he had died and then transported by the funeral director into the care of the anatomy department. Whether he had family, whether they supported him in his decision or how they felt about the lack of the normal ritual of a funeral, I would never know.
In a tiled, dark and clinically soulless room in the basement of the anatomy department at Marischal College, hours after Henry’s death, Alec the mortuary technician had removed Henry’s clothing and personal effects, shaved his head and attached four brass identification discs – each threaded with a piece of cord and stamped with a sequential identification number – to his smallest fingers and toes. These would stay with Henry throughout his time at the university. Next Alec would have made a cut in the skin of Henry’s groin, about 6cm in length, and dissected away the overlying muscle and fat until he could locate the femoral artery and vein in the region of the thigh known as the femoral triangle. He would then have made a small longitudinal incision in the vein, and another in the artery, where he inserted a cannula, securing it in place with some more cord. When a tight seal had been achieved, a valve in the cannula would have been opened and a solution of formalin would have perfused gently through Henry’s arborescent arterial system, driven from a gravity-feed tank above him.
The embalming fluid would have found its way via the blood vessels to every single cell in his body – to the neurons in his brain, where he used to think about all the things that mattered to him; to his fingers, which had held the hand of someone he cared about; to his throat, through which his last words had been spoken, perhaps only hours before. As the formalin solution slowly pushed its way onward, in an irreversible wave, the blood in his vessels would have been purged and eventually much of it would have washed away. After only two or three hours of this quiet, peaceful embalming process, his body would have been wrapped in plastic sheeting and stored until it was needed, maybe days, maybe months later.
In that short interval, Henry had been transformed, of his own volition, from a man known and loved by his family into an anonymous cadaver identified only by a number. That anonymity is important. It protects the students and helps them to mentally separate the sad death of a fellow human being from the work they are doing. If they are to dissect a cadaver for the first time without experiencing crippling empathy, they must, while remaining respectful and ensuring that dignity is preserved, be able to train their minds into viewing the body as a depersonalised shell.
When the time came for Henry’s body to play its part in our first anatomy class, he had been placed on a trolley, brought upstairs to the dissecting room in the old, rickety, noisy lift, transferred on to one of the glass-covered dissecting tables and covered with a white sheet to wait, quietly and patiently, for his students to arrive.
Today we go to great lengths to make our students’ first dissection as memorable and atraumatic as possible. Most of them, like me, will never have seen a dead body before this moment. In 1980, when I embarked on anatomical dissection, there were no introductory sessions, no gradual process of getting to know the cadaver that would be our silent teacher for the next few months. We were four very scared third-year undergraduates who, on arriving that Monday morning armed only with our copies of Snell’s Clinical Anatomy for Medical Students, a dissection manual – G.J. Romanes’ Cunningham’s Manual of Practical Anatomy – and a selection of scary dissecting instruments wrapped up in a khaki-coloured cloth roll, were pretty much left to just get on with it, beginning at page 1 of the manual. We didn’t use gloves or wear eye-protectors, and our laboratory coats very soon became an utter disgrace as we were not allowed to take them out of the building to wash them. How times have changed.
On our table, Graham and I found an array of sponges, which we quickly learned were essential for mopping up excess fluid as the dissection progressed. They had to be wrung out frequently. Underneath it was a stainless-steel bucket for collecting pieces of tissue when our dissection was complete for the day. It is important that all the parts of a body remain together, even when they amount to no more than small bits of muscle or skin, so that when it is sent for burial or cremation it will be as complete as possible. Standing sentinel at our side, watching and waiting, was a second influential tutor: an articulated human skeleton, there to help us understand what we would see and feel under Henry’s skin and muscles.
The first thing to master was how to put on a scalpel blade without slicing your finger off. Lining up the narrow slit on the blade with the ridge of the handle, then guiding it with forceps until it clicks into place, takes some dexterity and practice. As does removing it again. I often think to myself that surely someone could come up with a better design.
If you cut into the cadaver and noticed it starting to bleed with bright red arterial blood, I was warned, just remember that cadavers don’t bleed. What you will have cut is your own finger. The scalpel blades are so sharp and the room so cold that you don’t feel them slicing into your skin. So the first indication that you have injured yourself will be the sight of scarlet living blood pooling against the pale brown of the cadaver’s embalmed skin. Contamination is not as much of a concern as it would be if we were handling unembalmed bodies because the process renders the tissue virtually sterile. Just as well, since dealing with fiddly little blades when your fingers are cold and slippery with body fat is not easy. These days we begin the academic session with a vast supply of sticking plasters and surgical gloves.
Once the blade is finally on your scalpel handle and your finger has stopped pumping blood, you lean over the table and immediately your eyes start to water from the formalin fumes. The manual has told you where to cut, but it doesn’t tell you how deeply, or what it will feel like. Nobody has given you explicit permission to ‘feel’ Henry’s anatomy so that you can figure out where to cut to and from, and none of it seems to make any sense. It is all a bit terrifying and faintly embarrassing. You pause for a moment to consider how you will make the incision down the centre of the torso, from the hollow of the sternal notch at the base of the neck to the lower border of the ribcage. Which of you will watch and which of you will make the cut? Your hand shakes. That first incision stays with every student, however blasé they pretend to be. If I close my eyes I can still remember what it was like, and how impeccably Henry tolerated our youthful ineptitude.
As your motionless teacher reclines in patient repose, waiting for you to begin, you inwardly apologise to him for what you are about to do, for fear you will make a mess of it. Scalpel in the right hand, forceps in the left … how deep do you cut? It is no coincidence that most students begin dissection with the thorax. The breastbone is so close to the skin that no matter how hard you try, there is little you can do wrong. You simply cannot go too deep. You lower the blade to the surface of the skin and draw it carefully down the chest wall, leaving a faint line in its wake.
It is surprising just how easily the skin parts. It is leathery to the touch, cold and wet, and as it separates from the tissue, beneath the blade you glimpse the contrasting pale yellow of the subcutaneous fat. Feeling a little more confident, you extend the incision from the sternum in the centre across both clavicles, out towards the tip of each shoulder and you have made your first ‘T’ postmortem cut. So much anxious anticipation and it is over in a moment. The world has not stopped. The relief is immense and only now do you realise that you have not breathed through the whole process. Though your heart is racing and your adrenaline is pumping, you are surprised to find that you are no longer afraid but intrigued.
Now
you need to expose the tissue underneath. You start to peel back the skin, picking carefully at the corner of the free flap in the midline above the breastbone, at the junction of the two limbs of the ‘T’. You grip the skin with the forceps, applying just enough tension to allow the blade to separate it from the tissue. You never really need to cut. The yellow fat appears and as this comes into contact with your warmer hands it liquefies. Holding the scalpel and forceps suddenly becomes tricky and the flicker of confidence you had a few moments earlier evaporates as the forceps slip off the skin and fat and fluid splash up into your face. Nobody has warned you about this. Formalin smells nasty but it tastes worse. You only ever make that mistake once.
Continuing to peel back the skin, you start to notice tiny red dots and realise that you have unavoidably cut across a small cutaneous blood vessel. Suddenly, the immense scale of the human form, and the vast amount of information it contains, hits home. The day before you might have been wondering how on earth it was going to take you a whole year to dissect a human body and why you needed three whole dissector volumes to instruct you. Now it dawns on you that a year will be nowhere near long enough to do much more than scratch the surface of your subject. You feel like the true novice you are. You despair that you will ever remember all you must learn, let alone understand it fully.
You put a little strain on the forceps and the sharp blade slices into the connective tissue with disconcerting ease, even though it seems to you that your scalpel is barely touching it. As the underlying muscles are revealed, the white transverse bony walls of the chest stand out starkly against them like a bleached toast rack. Your eyes trace the shape of the hollows and ridges of the skeleton at your side as you feel beneath your fingertips Henry’s muscle and bones. You begin to identify and name the bones and their constituent parts – the scaffolding of the human body – and before you know it, you are speaking an ancient language understood by anatomists all over the world: a language that would have been familiar to Andreas Vesalius, the fourteenth-century founder of modern anatomical study and my undisputed girl crush.