Now Austen reached into the abdomen, feeling around among the intestines. She removed the small intestine, pulling it out like rope, foot by foot, cutting the membranes that held the masses of intestines together. There was a sour reek, and a quantity of chyme squeezed out of the small intestine, like toothpaste coming out of a tube. Chyme is a soft gray paste that looks like oatmeal. It is partly digested food from the upper intestine, food that has not yet met the bile and darkened. She placed the small intestine in a cylindrical steel wash tank full of running water that sat at the end of the autopsy table. The tissue seemed healthy and normal.
She found the liver and pulled it up to look at it. The liver appeared normal in color: dark reddish brown. She removed the liver and weighed it on a scale over the table. “Liver’s thirteen hundred and fifty grams.” She put it down on the cutting board and sliced it quickly, then dropped a sample of liver into the stock jar, and another piece of liver into the tox container. She cut open the stomach and looked inside at the contents. Kate Moran had not eaten in a while.
Austen lifted the bowel out, holding it in both hands, loosely folded. This she handed to Ben Kly. He placed the bowel in the wash container and squeezed it and rinsed it, like hand laundry. Masses of feces floated away in the wash water and swirled down the drain. A stench of feces filled the air.
The body cavity was open and almost empty now, a red gaping cave of ribs. The girl’s face was not visible. It was still covered with the blanket of chest skin.
Kly was standing close to Austen, looking into the body cavity.
“Find her soul, Ben?” Dudley said.
“It’s gone to a better place, Doctor,” Kly answered.
There were still the pelvic organs to remove. These are the organs that are tucked inside the pelvis (the hip bones). The pelvic organs open out through the natural openings between the legs.
Austen reached down through the abdomen, low inside the girl’s pelvis, and grasped the vagina and rectum with her left hand (her chain-mail hand). With her right hand, she inserted a scalpel deep down into the pelvic area. Working delicately, by sense of touch, she cut through the base of the rectum, through the vagina, and she cut away the bladder at the base of the urethra. As she was cutting, she pulled steadily. Nothing happened. She pulled harder. The bundle of organs were suddenly freed, and they came out of the body with a bubbling squelch. The sound is known as the pelvic slurp, and it is caused by a suction drawing air inward as the organs are pulled out of the pelvis.
Austen lifted out the block of pelvic organs: the rectum, vagina and uterus with the ovaries, and the bladder. They hung together in a single baglike unit, a sac of organs that weighed about five pounds and wobbled and pendulated in her gloved hand. She placed the mass on the cutting board. It was soft, and spread out like jelly.
She began to feel cold. She wished they didn’t keep the air quite so cool in here. She cut the pelvic organs apart from one another with scissors. She opened the bladder. It was empty.
Austen turned her attention to the kidneys. They were lying on the cutting board. She trimmed the kidney fat off them, and then she sectioned a kidney with her knife.
The kidney fell in half.
It was unusual.
She saw delicate golden-yellow streaks of color in the renal pyramid, in the center of the kidney. This was abnormal. The kidney should be a dark reddish-brown color, not golden and streaky. So often in an autopsy, color carries meaning. A golden kidney, that was unusual.
“Look at this, Dr. Dudley.”
The two pathologists bent over the kidney. Austen sectioned the other kidney, and found golden streaks in it, too. She cut chunks out of both kidneys and put the chunks in the stock jar and in the tox container.
“That yellow tissue is dead,” he said. “Those are uric acid infarcts, looks like to me. That tissue was killed by deposits of uric acid crystals.”
“She seems healthy. Why would she have a lot of uric acid in her blood?”
“Maybe it’s not uric acid. It could be a toxin. That would cause the blistering in the kid’s mouth. Maybe she was getting chemotherapy for cancer. That would blast the kidneys.”
“But there’s no sign of cancer.”
Austen turned her attention to the rest of the pelvic organs. She separated the rectum from the uterus, snipping through the membrane that joined them. She placed the rectum on the cutting board and split it with scissors, opened it up, and flattened it out, smoothing the rectum with her fingers.
She placed the vagina, uterus, and ovaries on the cutting board. She split the vagina with a knife. The inside of the vagina was speckled with a few blood blisters. Several had broken; perhaps that was what had stained the tampon. She snipped open the uterus with scissors. The tissues were in an early menstrual stage.
Austen sectioned one ovary with a scalpel. The girl’s ovary fell apart under her blade. Cells in the ovary can become an adult human being. Looking at Kate’s ovary gave Austen a deep feeling, and made her conscious of her own pelvic organs, her unknown future, the probability or hope that someday she would become a mother. This was the girl’s motherhood being laid apart under the knife, a future that had ended like a door slamming shut. The tissues of the ovary were unremarkable.
She caught Ben Kly’s eye. “Cranial contents,” she said.
“Okay.” He lifted up the girl’s head and placed it on a hard rubber head block. The head block is an H-shaped chunk of black vulcanized rubber. It is used in autopsies to hold up the head and get it off the table, so that the skull can be cut open. He removed the chest skin from her face.
Austen took up a scalpel. She bent down to the level of the table and looked at the side of the girl’s head, judging the best place to start the incision. With one hand, she lifted up the russet hair to get it out of the way. She put the scalpel on the skin just above the ear, pushing the tip straight in until it touched bone. Then, slitting the skin rapidly, she made an incision over the top of the head, a coronal incision running from ear to ear, cutting through the scalp. The scalp tissue parted with a slurping sound. It looked like the lips of a mouth opening across the top of the head. Some blood dripped onto the table, forming red puddles on the steel.
Now she gripped the scalp and pulled it forward, peeling it off the skull. There was a faint ripping sound as she pulled. The scalp lifted away very easily. She pulled the scalp and hair forward and then down over the face. As she did this, the whole face was compressed like a piece of rubber. Kate’s eyes opened and sagged downward, and her face collapsed, creating an expression that seemed as if she were experiencing the deepest grief in the world. The scalp was now reversed and hanging down from her bare forehead bone, covering her eyes, so the wet, glistening, red inner layer of the scalp was on the outside, like a hat pulled down low. Her hair was underneath it, like a rug turned upside down and lying on her face. A brush of matted hair stuck out from underneath the reversed scalp. This hair hung down and covered her nose and mouth. Then Austen pulled the scalp down off the back part of the skull, down almost to the top of the neck. This revealed the glistening-wet ivory-colored dome of her skull.
It is the task of the morgue attendant to open the skull. Ben Kly took up a Stryker saw and plugged the cord into a socket under the table. A Stryker saw is a power tool with a cutting blade that moves back and forth, rather than spinning around. Kly switched the saw on, and it gave off a chattering whine. He adjusted his safety glasses—you want to make sure your eyes are protected if you are using power tools that throw blood and particles around. The Stryker saw dug into the skull.
A cloud of mist appeared in the air around the girl’s head. It drifted and coiled and snaked up from the blade of the Stryker saw, moving like cigarette smoke, and there was a sudden, sharp smell of bone. The “smoke” was bone dust. It had a piercing odor, strong and unpleasant. It resembled the smell that occurs in a dentist’s office when a high-speed drill is cutting into a tooth—a smoky, bony, warm, bloody, wet stench.
Kly grimaced, bearing down hard on the Stryker saw. The cut circled the head. He finished the cut at an angle, making a V notch in the forehead. The notch was so that he could fit the skull bone back on properly afterward, matching the shape of the cut.
Then he took up a steel T-shaped bone chisel. He inserted it into the saw cut, and twisted the chisel. There was a cracking sound. He put it in another place and pried again. More cracking sounds came from the skull. He pried gently, here and there. Then he lifted off the top of the skull. It was a section of bone known as the calvarium. He held it in his hands, upside down. The calvarium was a dish of bone the size and shape of a soup bowl. It was the top of the girl’s skull. A pool of blood had collected in the bottom of the calvarium. It was a bowl of blood.
“Calvary,” Kly said in a dreamy way. “The Place of the Skull.” He placed the bone on the autopsy table, where it rotated slowly.
“You read the Bible too much,” Dudley remarked.
“I don’t read it enough,” Kly answered.
He had exposed a gray, leathery membrane that covers the brain, a membrane called the dura mater.
Austen continued from that point. She ran her hand over the dura, feeling the membrane. It seemed tight and swollen to her, but that was hard to tell. She took up blunt scissors and carefully cut the dura mater, snipping it away. She peeled it back. The folds of the brain came into view.
The brain was swollen, bulging like a strange forest mushroom. It had an eerie, abnormal, pearlescent color. It was a color that neither pathologist had ever seen in brain tissue before.
“Whoa,” Dudley said.
Austen’s heart thudded in her chest. This is a destroyed brain, she thought. She felt a mixture of fear and excitement.
“Flattened folds,” Dudley said.
The folds of the human brain are ordinarily deep and sharply grooved. This brain had turned a silvery color and had puffed up like a balloon. The folds of the brain had been smashed up and pressed flat into the dura mater. The brain was smoothed, swollen, and flattened—as if the wrinkles had been pressed with an iron. This was a technical term, an ironed brain. It was almost as if the brain had exploded, bursting against the inside of the skull.
Austen touched the brain surface. It was very, very soft, like gelatin that had not set properly. The brain was a destroyed mess, almost liquefying. How to remove it? It could fall apart.
Gently, Austen pushed the fingers of her left hand, the chain-mail hand, in around the frontal lobes of Kate Moran’s exploded brain. She was feeling her way behind the bones of the forehead, trying not to tear the brain. She pulled the brain back slightly with her left hand, and then, with her right hand, working entirely by sense of touch, she slid a scalpel down low under the front of the skull. With the blade she began probing for the optic nerves, the nerves that connected the brain to the eyes. She couldn’t see the scalpel blade, and so she felt around with it, using her sense of touch. She found the optic nerves and cut them. She wiggled the brain and it loosened.
The removal of a person’s brain seemed to Austen more of a violation of the person’s dignity and privacy than any other procedure in the autopsy, because the brain is the most personal part of the body; the only body part that studies itself. Alice Austen felt that the life of a human being has a sacred quality. She did not know if she believed in the soul; that seemed a difficult question to answer. But she believed in the sacredness of human life. One very important way to honor life is to try to find out how it ended.
Austen pulled the brain backward, rolling it and lifting it. This brain is impossibly soft, she thought. Finally she had lifted the brain enough to gain access to the top of the spinal cord. With a quick angling slice of the scalpel she cut the spinal cord, and the brain fell into her hands.
Cradling the organ in her cupped hands—it was hugely, abnormally heavy, engorged with fluid, and so jellylike it threatened to slop apart—she placed the brain in the scale pan and weighed it.
“Oh, wow. Sixteen hundred and twenty-five grams,” she said. It was a superfat brain.
Keeping her hands cupped around the brain, she lowered it to the cutting board. Then she turned the brain over, upside down. She let it go, and it spread out under its own weight, like a blob. It flowed over the cutting board like a bag of water, it was so soft.
It was a spotted blob.
The underside of the brain was speckled with tiny red spots.
She stared at the spots. They were small red speckles, tiny, less than a millimeter across. They were starlike hemorrhages. Yet there had been no general bleeding in this brain, no massive hemorrhage. It was a glassy, swollen brain speckled with red spots.
When a person gets measles, the skin erupts with red spots. The brain, when infected with a virus, also can become spotty.
She became aware of the fact that she was alive and this brain was not alive. But it might have something alive in it. “I see a lot of small bleeds,” she said to Dudley.
Austen began trying to make a diagnosis. The word diagnosis in Greek means “knowing through.” In a successful diagnosis, you search through possibilities, casting them aside, ruling things out, until at last there comes a sensation of a click, a locking in place, and the fragments of a puzzle snap into a clear picture.
She was missing something. What was it? She moved around the table, to reposition herself for further examination of the brain. In doing so, she brushed against the calvarium—the top of the skull—which was lying upside down on the table, with the pool of blood in it. It was getting in the way, so she picked it up in order to move it to a different place, and it slipped from her already slippery fingers. It hit the blood-covered metal of the table with a clang, and a fine spray of blood droplets went into the air.
“Damn!” Dudley said, drawing back.
There were tiny spots of blood on his eyeglasses.
“Good technique,” he said.
“I’m sorry. I’m very sorry.” A wave of nervousness swept over her, and her stomach clenched. “Did you get any in your eyes?”
“No. Fortunately. That’s why we wear eye protection.” He had a cold look on his face.
There was nothing to do but keep going. Looking at the brain, she saw the effects of brain swelling. The brain is encased in a hard skull, and when it swells, through injury or infection, it has nowhere to go. So it destroys itself. The brain puffs up with fluid—in the way any injured tissue does—and it crushes itself.
The swelling brain pushes downward on the deep structures at the top of the brain stem, especially on the midbrain. The midbrain is an old brain, a primitive brain. It contains nerve branches that control basic functions such as breathing and heartbeat, and it contains the nerves of the face; it also contains the nerves that govern the action of the irises of the eyes in response to light. If you crush the midbrain, these nerves are destroyed. The pupils dilate and become fixed, breathing ceases, and the heart stops beating.
Austen saw deep grooves in the underside of the brain. These grooves were a sign of rupture of the brain: the brain had almost literally burst. It had changed shape as it puffed up and died. The moving finger had written its message on Kate Moran’s mind: she could not have been saved by any medical procedure. This was a hopeless case. By the time the girl collapsed, she was doomed.
As the brain crushes itself, the blood pressure can shoot sky high. This is a shock response known as the Cushing reflex. It happens in the moments before death. The brain must have blood, and as the swelling begins to close off the arteries that supply blood to the brain, and as pressure in the brain rises, the body drives up its own blood pressure to meet the rise in brain pressure. The body is trying to drive blood into the brain at all costs, because if the blood supply to the brain is lost, the brain stops functioning in a matter of a few seconds. Thus there can be a tremendous terminal spike of blood pressure. As the patient approaches death, the systolic blood pressure soars as high as 300. Normal systolic pressure is about 120. The s
udden spike in blood pressure during a Cushing reflex can trigger hemorrhages, sudden bleeds anywhere in the body. The pressure soars, the pipes burst. The patient starts to bleed, the patient dies. That, Austen thought, was the cause of the girl’s bloody nose. Her blood pressure had spiked, causing a hemorrhagic nosebleed at the point of death.
“This could be a virus infection of the brain. It led to brain swelling, which was the immediate cause of death,” Austen said. “It triggered a Cushing reflex with a bleed from the nasopharynx.”
Dudley looked at her. “Fine. We have an unknown brain virus that caused a nosebleed. Is that what you’re trying to tell me?”
“This scares me. I’ve never seen anything like it. I want to section this brain,” she said.
“The brain’s a mess,” Dudley said.
“I want to try.”
“Go ahead.”
She dipped her knife in the water of the rinsing tank, to wet it and make it slippery. She laid the edge across the brain, in a coronal section, as if going from ear to ear, and she sliced downward crisply in a smooth motion. She sliced again and again, her knife moving quickly, making slices that were about the thickness of slices of bread.
The brain slimed apart. As her knife hit it, it slumped into a kind of glassy, red-gray mush. Austen ended up with a slippery jumble of bloody-wet brain tissue that seemed to gleam with a pearlescent color under the lights. It spread out in a soupy mess on the cutting board.
“You’ve ruined it!” Dudley said.
Austen said nothing. She was tempted to warn him to back off.