“I’ve never worn one,” she said.
They put on plastic safety glasses, to prevent blood or fluid from splashing into their eyes. Dudley didn’t need safety glasses, since he was already wearing eyeglasses.
They put on rubber surgical gloves.
Then Glenn Dudley fitted a glove made of stainless-steel chain mail over his left hand. The chain-mail glove indicated that he was going to be the prosector—the leader of the autopsy, the person who did the cutting. In the New York O.C.M.E. the prosector wears a metal glove on one hand; it is a sign of medical authority and, more important, a safety measure. Most accidental knife cuts during autopsy occur on the pathologist’s nondominant hand. In most people that’s the left hand. You hold the knife in your dominant hand, so accidental cuts usually occur on the nondominant hand. You wear a chain-mail glove on your nondominant hand.
They put on heavy yellow rubber dishwashing gloves over their surgical gloves. Dudley drew a rubber glove over his metal glove.
“The decedent is in 102,” Ben Kly said.
They followed Kly through the morgue as he wheeled an empty pan around the ring-shaped room to a stainless-steel door, crypt number 102. Inside, lying on a tray, was a white body pouch. A stale odor came out of the crypt.
“Dr. Austen, the smell doesn’t affect you?” Nathanson asked.
“It’s a little stronger than what I’m used to.”
“They do them fresh in hospitals,” Ben Kly remarked, rolling out the tray. A human form gave shape to the white pouch.
Nathanson said, “Manhattan is not like other places. People come to Manhattan to live alone. It means they often die alone. We handle a surprising number of putrefied bodies. What you are smelling is the stench of loneliness, Dr. Austen.”
Kly took the shoulders, grasping them through the pouch, while Dudley took the feet. In one expert motion they lifted up the body and transferred it to the pan. Kly wheeled it over to a floor scale and read the dial. “A hundred and eighteen pounds,” he said, writing it on a clipboard.
He pushed the gurney through a pair of doors into the autopsy room.
“Welcome to the Pit,” Kly said.
The autopsy room was seventy feet long, and was partly underground. In it stood eight stainless-steel autopsy tables, lined up in a row. This was autopsy central for Manhattan, one of the busiest autopsy rooms in the world. Four of the tables had pathologists working at them; they were in the process of laying out bodies, preparing to go to work; some had begun cutting. The Pit was a gray zone, a place neither definitely hot nor definitely safe. It was somewhere in between. An ultraviolet light on the wall shed rays into the room that were supposed to kill airborne pathogens, viruses and bacteria. On the floor, air-filtering machines hummed, cleaning the air of infective particles that might get into the lungs of the pathologists.
Ben Kly halted the pan next to an autopsy table and set the brake. He unzipped the white bag.
Kate
HER EYES WERE CLOSED, the eyelids puffy. She had had a streaming bloody nose, and the blood had run over her chin and pooled in the hollow of her throat. Someone, probably a busy nurse, had attempted to wash her face, but the washing had not been thorough.
People are fastidious by nature, and have a hundred ways of grooming their bodies and keeping order about their persons. When a person dies, the ways of grooming vanish. The first impression one has of a dead person is of disorder—unkempt hair, purposeless limbs, blotchy moist skin with specks of dirt on it, eyes half open, a faint meaty unwashed smell.
Her teeth were visible in a grimace behind shredded lips. The teeth were stained with brownish blood. Her hair was russet, shining and beautiful, wavy hair. With a start, Austen saw that the girl’s hair was the same color and texture as her own hair. There were two rings in her left ear.
“Her name is Catherine Moran,” Nathanson said. “Our medicolegal investigator talked to some of her teachers yesterday. They called her Kate.”
Ben Kly unzipped the pouch completely. The dead girl was wearing a short hospital gown, as if for modesty.
Dudley opened the investigator’s report, a collection of sheets of paper in a manila folder.
“Case number 98-M-12698,” Dudley said, reading from the file. “She collapsed in a school classroom.” His eyes glanced rapidly over the report. “Mater School, on Seventy-ninth Street. She became extremely ill in class. Yesterday. About ten-thirty in the morning. She fell to the floor. She was grimacing and biting her lips—biting herself, chewing her lips and swallowing them—grand mal seizures—heavy nosebleed—sudden unexplained death. Yeah, and they reported she went into a hard tonic seizure at the end. Superficially, the case looks like Harmonica Man—you’ve got the wild seizures, the hard clonic tensing of the spine, the bleed, the chewing. She was D.O.A. at New York Hospital. It made the news last night.”
“You’ve got a homeless man and a young woman from a well-to-do background,” Nathanson remarked. “That in itself stands out. There’s no obvious connection between them.”
“Drugs,” Dudley said.
“It’s almost like there was a demon inside them,” Ben Kly whispered.
“Want to call in a priest, Kly?” Dudley said.
“I’m a Presbyterian,” Kly answered.
“The hospital did a blood and spinal workup?” Austen asked.
“They didn’t run any tests—she was pronounced dead,” Dudley replied.
Dudley and Kly lifted the girl out of the pouch and transferred her to the autopsy table. The inside surfaces of the pouch glistened with droplets of black blood. They stretched her out on her back, on the heavy steel mesh of the table, with water running underneath the mesh. They removed the gown. Her breasts were small. Her body was young.
The appearance of Kate’s body disturbed Austen. The truth was that the girl looked very much like her. She could be my younger sister, Austen thought, if I had a younger sister. She reached out and took the left hand of the girl in her gloved hand. She lifted the hand up gently and looked at it. The fingernails were delicate.
“Someone could have given her a hot load, Lex,” Dudley said.
Austen frowned, puzzled.
Nathanson explained, “A lethal dose of bad drugs, Dr. Austen. A hot load. Dealers do it when they want to get rid of a customer.”
“That would make it a homicide, but it would be hard to prove,” Dudley said.
Nathanson suddenly said, “Dr. Austen—I’d like you to be the prosector for this one. You can do the autopsy.”
“But I came here to observe.”
“I think your insights into this case could be interesting,” Nathanson said. “Ben, she’ll need a chain-mail glove. You’ll use your own knife, I assume.”
She nodded.
Kly got her a chain-mail glove. She put it on her left hand and replaced the yellow rubber glove. She opened her prosection pack and removed her steel knife.
“Glenn will help you with the forensics, and he’ll sign the documents,” Nathanson said.
Nathanson left to make his rounds in the Pit. He passed by the autopsy tables one by one, stopping to chat with pathologists, having a look at each of the day’s cases. As she watched him walk away, Austen felt that he had been sizing her up from the moment they met. From the beginning, he had been thinking of turning the autopsy over to her, but he had held off making the decision until the last possible moment. She watched him out of the corner of her eye.
Dudley said to Austen in a low voice, “I never saw the point of Lex’s calling the C.D.C. It was something he wanted to do, not me. You will follow my direction. Is that clear?”
“Yes.”
“The last thing we need around here is a C.D.C. trainee who’s carrying on her education in public.”
Ben Kly pretended not to hear a word of this. He took up a rubber hose and rinsed the girl’s body gently with running water.
Across the tables, the day’s work had gotten under way. A flash went off on the other side of
the room. A photographer was standing on a ladder, taking pictures of a shooting victim, a young Hispanic man who had been caught in a heroin deal gone bad. They had peeled off his bloody clothes and hung them to dry on a hat stand, and a pathologist was writing on tags with a Magic Marker and tying the tags to the clothes, while a New York City homicide detective stood by and watched. Another table was getting a lot of attention. On it lay a naked woman. She was marked with bruises about the chest and head, she appeared to have a fractured skull, and there were deep stab wounds in her belly, which was very large. Eight months’ pregnant, she had been beaten and stabbed to death by her husband. A fetus had apparently died of stab wounds inside her. Someone at another table said, “Who’s got the loppers?” A hot smell of intestinal contents filled the air, a smell that resembled the foulest diarrhea. There was the murmur of voices, as pathologists chatted with one another across the tables. The Pit was one of the beating centers of life in New York City, essential to its daily existence, yet unseen and unimagined by most people who lived in the city. The case of the girl who had collapsed in school was not getting much attention from the other pathologists.
Dudley called over the photographer, who took a few pictures of Kate Moran. Then Austen and Dudley together did an external examination.
In the bright fluorescent light, they looked at the skin. They rolled the body sideways and examined the girl’s back, then rolled her so that she was resting on her back again. When a baby is born, the attending pediatrician examines the baby’s genitalia, to check for malformation. At the other end of life, the pathologist performs a similar examination. Austen parted the girl’s legs and looked carefully there. She saw a string and some blood. The girl had been having her menstrual period. Pulling the string, she removed the tampon and looked at it, turning it over in her gloved hands. It bore a few spots of bright red blood.
An experienced morgue attendant, or diener, can help find things. Ben Kly pointed to the girl’s nose. “Lot of mucus there.”
Austen looked. Coming out of the girl’s nose, along with the blood, was a slick watery fluid, a fair amount of it. “You’re right,” she said. “It looks like she had a cold.”
“She has a cold,” Kly commented.
“What?” Alice said, looking at him.
“You know how a cold survives in a dead body?” Kly said. “I’ve caught colds from bodies. Cadaver colds are the worst. I think that cold gets mean sitting in that body, saying, ‘This guy is dead. Get me out of here.’ ”
“I wonder what else you guys catch,” Dudley said to him.
“Hey, I’ve worked in the morgue for seven years,” Kly replied, “and my immune system is like a rock by now. Nothing can get past it. Except every October I get my cadaver cold, as regular as an alarm clock.”
Austen wanted to inspect the girl’s mouth and tongue. She opened the mouth and grasped the tongue firmly with a forceps, and pulled the tongue partway out of the mouth.
Her mouth was stained with partly coagulated blood. Austen moved the tongue sideways. “She bit her tongue and lips,” she said. “There are molar cuts toward the back of the tongue.” She had shredded her lips with her front teeth, it seemed, and a portion of lip was missing. But that was not all. The inside of the mouth had the wrong texture and color, but the blood obscured it. Austen bent over and looked very closely, and now she saw something. The inside of the mouth was shining with blisters. They were very dark. They were blood blisters, it seemed.
Next came the examination of the eyes. Gripping the eyelids delicately with a small forceps, Austen rolled them back one at a time.
The inside of the eyelid was peppered with small red dots.
“She’s got inflammation of the conjunctiva,” Austen said.
Now she looked at the eye. The iris was blue-gray, but with a hint of golden yellow. Austen bent down until her face was inches from Kate’s, and she stared into the pupils, left and right. In the cornea was reflected the blue glare of the overhead fluorescent lights and her own face, with the mask over her mouth and nose, and the safety glasses over her eyes. Pathology, above all, is the act of seeing. Seeing with understanding leads to diagnosis. Austen continued to stare into Kate’s eyes, trying to understand what she was seeing, trying to recognize a pattern. Her eyes had an abnormal color, she thought. There seemed to be a ring of yellowish shiny pigment inside each iris—a pupillary ring, with flamelike offshoots. It had formed a kind of iridescent circle fringing the black dot of the pupil. The ring had a metallic sheen, like the wing of a tropical butterfly, with a predominantly yellowish cast, and it made the pupil look as if it had caught fire.
“These eyes seem unusual, Dr. Dudley. What do you think of the color in the iris?”
“Huh.” Dudley bent over to look. “It’s natural color. The conjunctiva’s inflamed.”
“But she has pupillary rings in the iris. Like some kind of crystalline or metallic deposit. I wonder if this is copper. She could have copper poisoning. These rings in the iris could be Kayser-Fleischer rings. That’s a copper deposit in the eyes. It’s a sign of Wilson’s disease—”
“I know what that is,” he said, looking at her. “Nope—no way. Rings from copper poisoning, Dr. Austen, would appear on the outside rim of the iris. This golden coloration is on the inside of the iris, near the pupil. It’s normal eye color.”
The girl had had a bloody nose. Austen decided that she wanted to look inside the nose. “Do you have an exam light?”
Kly found a standard examination light and handed it to Austen. She pointed the light into Kate’s nostril and looked.
The nasopharynx is like a cave inside the head. This cave was clogged with congealed blood. Then Austen saw it: blood blisters in the cavity. They gleamed in the light.
“Wow,” Austen said. “There’s a blistering process.” She thought: the bloody nose could be a broken blister.
“Let me look,” Dudley said. He took the light. “Yeah. What the hell is that?”
“She has similar blisters in her mouth. This looks like an infectious-disease process, I think.”
“Yeah. Or hemorrhages. This could be a toxin, a poison of some kind. Go ahead and open her,” Dudley said to Austen.
Ben Kly prepared a fresh scalpel, snapping a clean blade onto the handle, and he handed it to Austen. She inserted the scalpel into Kate Moran’s right shoulder. With a quick, careful, deft motion she ran the scalpel down from the shoulder and underneath the young woman’s breast, then across her rib cage, bumping over the ribs. She reached the point of the sternum, where the ribs come together at the top of the abdomen, and from that point she cut straight down the abdomen, heading for the navel. She made a detour around the navel, still cutting. She stopped the cut when it reached the pubic bones of the pelvis, at the top of the pubic hair. As the skin of the abdomen parted, a strong whiff of feces filled the air.
Now Austen made a second cut, starting at Kate’s other shoulder and running down and across her chest to her sternum, where the cut joined the first cut. The two cuts thus formed a Y. The points of the Y were in the shoulders, and the joint of the Y was at the bottom of the rib cage. The shaft of the Y ran down over the abdomen to the pubis. Her skin gaped open, the yellow body fat revealed.
“Ephaphtha,” Ben Kly said softly.
“What was that?” Austen said, glancing at him.
“Ephaphtha. It’s a good-luck word. It’s what Jesus said when he threw a demon out of a deaf-and-dumb man. He stuck his finger into the guy’s ear, and he put a dab of his spit on the guy’s tongue. Then he said, ‘Ephaphtha.’ It means, ‘Be opened.’ And the demon came out.”
“The Lord guides our diener’s hand,” Dudley remarked.
“He guides our prosector’s hand,” Kly said quietly.
Using the scalpel to cut away fat and tissue, Alice Austen gently pulled back the underlying tissue of the girl’s chest. She reflected (laid back) the large flaps of skin, exposing her rib cage. She laid the skin of the chest backward and
inside out, like a blanket, over the girl’s face. The breasts were turned inside out, the breast tissue seen from the inside, white and milky in color, while the outside of the breasts lay upon Kate’s face.
Kly handed Austen a pair of lopping shears—the kind gardeners use to trim branches—and she cut the girl’s ribs. The ribs gave off cracking sounds as they broke. Then she lifted away the chest plate, the central section of the rib cage. She laid the chest plate on the table.
Austen reached into the chest cavity with her fingers and gently pulled the lungs away from the heart, which was encased in a membrane. “I want to get a blood sample,” she said.
“You’re going to take a blood sample from the heart?” Dudley said sharply. “If you’re testing for infective agents, you’ll want to take blood from the leg, not the heart. Don’t you know that?” He went on to say that the heart would be contaminated with many kinds of bacteria, and thus it would not give a reliable biological sample of blood.
Austen turned red. “Okay,” she said.
Dudley had a look of satisfaction on his face. He handed Austen a syringe. She slid it into the femoral vein of the girl’s leg in the groin area. She found the vein on the second try and withdrew a small amount of blood and squirted it into two jars of blood-culture fluid, which is the color of beer. Any bacteria in Kate’s blood would grow in the liquid and could be observed and tested.
Then she lifted out the heart and lungs. She laid them on a white plastic cutting board. She sliced open both lungs with her knife. The lungs were heavy and dark. Kate had inhaled blood from her nosebleed. But the blood in her lungs was not enough, Austen thought, to be the cause of death. Not enough blood to drown the lungs.
With blunt scissors, she cut open the heart and examined the chambers, and she snipped open the coronary arteries. Kate Moran’s coronaries and heart were normal, unremarkable.
She cut away one-inch chunks of heart tissue and lung tissue, and dropped them into a large glass jar full of formalin preservative, a clear, poisonous fluid that looks like water. This jar was known as the stock jar. It would be sent to the O.C.M.E. histology lab, where slices of the tissue in the jar would be prepared for viewing through a microscope. Austen also prepared a separate toxicology container, a plastic container with no preservative in it. The O.C.M.E.’s toxicology lab would test the samples in this container for toxins and drugs. She dropped raw pieces of lung into the tox container.