T1 – 002: One Cadaver

The Lamentation over the Dead Christ by Andrea Mantegna

Via Abby Haglage:

It’s a phenomenon O’Sullivan witnessed firsthand in Sierra Leone. “People have no idea how infectious diseases work. They see people go into the hospital sick and come out dead—or never come out at all,” he says. “They think if they can avoid the hospital they can survive.” This mistrust of the medical world seems to be validated when a family is prohibited from honoring the dead, participating in the funeral, or even seeing the body.

Prior Ebola outbreaks in Africa, specifically in Uganda in 2000, have yielded similar reactions among afflicted communities. Dr. Barry Hewlett and Dr. Bonnie Hewlett, the first anthropologist to be invited by WHO to join a medical intervention team, studied the Ugandan Ebola outbreak. In a book cataloging their experience—Ebola, Culture, and Politics: The Anthropology of an Emerging Disease— they explore the dangers of African burial rituals, as well as the dangers of prohibiting them.

In the Ugandan ceremonies the Hewletts witnessed, the sister of the deceased’s father is responsible for bathing, cleaning, and dressing the body in a “favorite outfit.” This task, they write, is “too emotionally painful” for the immediate family. In the event that no aunt exists, a female elder in the community takes this role on. The next step, the mourning, is where the real ceremony takes place. “Funerals are major cultural events that can last for days, depending on the status of the deceased person,” they write. As the women “wail” and the men “dance,” the community takes time to “demonstrate care and respect for the dead.” The more important the person, the longer the mourning. When the ceremony is coming to a close, a common bowl is used for ritual hand-washing, and a final touch or kiss on the face of the corpse (which is known as a “a love touch”) is bestowed on the dead. When the ceremony has concluded, the body is buried on land that directly adjoins the deceased’s house because “the family wants the spirit to be happy and not feel forgotten.”

According to the Hewletts’ analysis, these burial rituals and funerals are a critical way for the community to safely transfer the deceased into the afterlife. Prohibiting families from performing such rites is not only viewed as an affront to the deceased, but as actually putting the family in danger. “In the event of an improper burial, the deceased person’s spirit (tibo) will cause harm and illness to the family,”

***

I have my own ritual involving the dead now.

The first cut was made sagittally, at the spine, from the external occipital protuberance to the iliac crest. I did not make it. Someone else in my group of six did. I don’t remember who, perhaps a future surgeon.

At the time, we barely knew each other. After sharing a body for over a month now, I feel like we know each other well. My first cut was made laterally, from the external occipital protuberance to the right mastoid process. I’ll remember it not because it was the first time I cut into a human being, but because I carelessly cut too deep and inadvertently severed the greater and lesser occipital nerves.

After making several sagittal, coronal, and transverse cuts, we removed the skin from the back down to the crest of the ilium, from the posterior surface of the neck, and from the posterior surface of the proximal upper limb. Then we removed fat and the superficial fascia. We had as much instruction as I just gave you.

I am not afraid to admit: I was surprised to learn that fascia existed. Prior to dissecting a human being, I believed earnestly that I knew at least all the major tissue components of the organism. I was mistaken. Like the spleen, fascia serves an essential, and undersung, purpose. It is as important as fat or muscle.

Next we cleaned the superficial surface and borders of the trapezius muscle; then we reflected the trapezius and latissimus dorsi. “Reflect” means to cut off at one end (muscles attach at two ends, or, more properly, they originate at one or more proximal ends and insert at one or more distal ends). After cutting a muscle, it is customary to fold it over to whichever side best allows the dissector to view the underlying tissue.

We next reflected the rhomboid major, the rhomboid minor, and the levator scapulae, bilaterally. God’s arbitrary choice that we should be bilateral beings very much benefits the anatomy student, since mistakes on one side can usually be redeemed on the other.

The intermediate muscles of the back are the serratus posterior superior and the serratus posterior inferior muscles. These muscles assist with breathing and are considered to be fairly unimportant, although they are assigned their own layer.

The deep back muscles – or “true” back muscles – such as the erector spinae spinalis, erector spinae longissimus, and erector spinae iliocostalis, are those that do not move the limbs or assist thoracic function but are involved in the various spinal movements. It is significant that the muscles traditionally regarded as “back” muscles, and those most prominent when one flexes one’s back, such as the trapezius and latissimus dorsi, are more accurately categorized as accessory muscles of the upper limb.

***

The first stage of decomposition after death is called autolysis. This term means “self-digestion”.

The enzymes that are necessary to break down and process proteins from your diet are normally tightly regulated when in use and actively sequestered in safe places within your body when not in use. Upon death, the various cells of the body begin to die from lack of oxygen, and membranes break down. Usually, brain cells are dead in five to ten minutes, whereas skin cells can live for up to a day or more without oxygen. Also upon death there is a cessation of the active processes that keep enzymes tucked away safely, and these enzymes are released into the cells and the various tissues. A process of autolysis results, whereby tissues of the body essential to life are broken down by the body’s own enzymes. In fact, autolysis is what occurs in pancreatitis, wherein damage to the pancreas results in the release of digestive enzymes into the pancreatic tissue itself, and a form of self-digestion occurs.

Once autolysis sets in after death and the tissues of the body are damaged, other organisms, such as insects or other scavengers, may also take advantage of the large-scale decomposition and use the corpse for food or as a breeding ground. The most widely known of these opportunistic organisms are maggots, however, bacteria that normally assist in digestion and live in symbiosis with their human hosts opportunistically take advantage of the new abundance of nutrients made available through autolysis, and these bacteria began to voraciously consume their former host shortly after its death. As a result of such activity of bacteria in the gut, gas builds up inside the body and leads to bloating. Often gas will accumulate inside the cadaver until the pressure is enough to overcome one or more of the body’s weakened tissues and forge an escape route. It is not unheard of for a corpse to explode.

The last stage of decomposition after death is putrefaction, wherein all the tissues of the body liquefy and melt into the surrounding environment. About three weeks after death, tissues and organ cavities are bursting, allowing for ventilation and increased environmental exposure for the cadaver. It is mistakenly believed that the hair and nails continue to grow after death. In fact, the hair and nails appear to grow only due to the differing rates of decomposition of the surrounding tissue: as the subcutaneous tissue beds collapse internally and the skin begins to shrivel, the hair and nails can become more prominent.

The first tissues to melt are those of the throat, followed by the rest of the alimentary canal, progressing inferiorly: first the stomach, then the small intestines, then the liver. The lungs melt next, followed by the brain and the heart, then the kidneys, the bladder, sex organs, the skin, and the muscles, The bones are the last tissues to liquefy, at rates slower than the other tissues by several orders of magnitude. While the rest of the corpse may have liquefied and disappeared into nature within a few months, bones can last for hundreds of years in soil of neutral pH.

Without that spark, that something, whatever it is that defines life, there is nothing protecting us from entropy.

***

After removing the erector spinae muscles, we could see the posterior vertebral arch and the laminae of the vertebral column. We used a bone saw to cut through the laminae. Once through, we removed the dorsal component of the spinal column to expose the meninges. After reflecting the components of the vertebral venous plexus blocking our entry to the cord, we used tweezers to pinch the dura mater, snipped a small amount of the pinch, and then “unzipped” the dural sack with a probe, inferiorly, to the S2 level. After examining the arachnoid membrane, and appreciating its delicacy, we cut this as well and entered the subarachnoid space, home of the spinal cord. In the spinal cord itself, I felt I was looking upon some holy object, in the innermost sanctum of the tabernacle.

We searched around for the cervical and lumbar enlargements, the conus medullaris and the cauda equina – or “horse’s tail” – inferior to the conus. This is the site of a lumbar puncture – a clinical procedure designed to induce spinal anaesthesia or to draw cerebrospinal fluid (a “spinal tap”) to check for subarachnoid hemorrhage, meningitis, latent tuberculosis, or other frightening diseases of the brain and spinal cord. We noted how the conus medullaris was tethered within the subarachnoid space by the filum terminale internum, and we also found as many as we could of the 21 sets of denticulate ligaments, which separate the dorsal (sensory) and ventral (motor) roots of the various spinal nerves, before they bulge at the dorsal root ganglia just about at the site of the intervertebral foramina.

***

The rate at which a dead body decomposes is based heavily on the surrounding environmental conditions: water and earth can slow the decomposition process relative to air; fire can accelerate decomposition.

Generally, the deeper a corpse is buried the slower its decomposition, and coffins can add weeks to months to the life of a corpse. Temperature plays a role as well: the hotter it is the faster the decomposition. Bodies decomposing in the tropics can become saturated with maggots or other insects five times faster than bodies decomposing in temperate climate zones. Such maggots alone are capable of consuming a human body down to the bones within a week.

Freezing a body can slow its decomposition. Nevertheless, since human bodies are comprised almost entirely of water, freezing without first removing liquid (i.e. through a process such as freeze drying) can result in the explosion of the tissues. Medical examiners use refrigerators to keep bodies just above freezing in order to stave off the decomposition process until an autopsy can be performed. As of 2014, approximately 300 people worldwide have undergone cryonic freezing after being declared dead. Cryonic freezing is an attempt to keep one’s body as pristine as possible in case future medical technologies might be able to bring one back from death.

***

After flipping our cadaver so that it was in the supine position – a task that required four people – we removed the skin of the anterior upper arm and pectoral region, making sure to preserve the nipple. We examined pectoralis major, pectoralis minor, serratus anterior, subclavius, and the external intercostal muscles. This was the first time our cadaver’s face was visible to us for the entire lab period.

Our cadaver is male. In order to study the anatomical structures of the breast – including the axillary tail of Spence, the ligaments of Cooper, the lactiferous ducts, and the lactiferous sinus – we received a breast from the group next to ours.

Radical mastectomy is a procedure that has been performed for approximately 140 years. It was the predominant treatment for any kind of breast cancer from roughly 1895 to 1975. Today it has very specific indications. Radical mastectomy involves the removal of the entire breast, the pectoralis major muscle, the pectoralis minor muscle, and the axillary lymph nodes. Since breast cancer is an especially aggressive malignancy, it was once believed that such aggressive treatment as radical mastectomy was necessary for all cases. There are cases reported, in the days before informed consent, of women going in for testing and waking up without a breast. I cannot imagine the profound sorrow such an event might have evoked for the women involved.

***

Much of what we know about decomposition today comes from research carried out by forensic anthropologists on body farms; yet, the preservation of human remains has a long, cross-cultural history.

The Egyptians are perhaps the culture best known for their skill at preservation of human remains, evident in the widely-displayed mummies that still contain the remains of soft tissue 5000 years after the host’s death. Nevertheless, the Chinchorro culture of the Atacama desert is known to have begun preserving human remains by 7000 BC, more than 4000 years before the Egyptians. Mummies outliving the civilizations that developed the techniques to preserve them have also been found in Ethiopia, Nigeria, Tibet, Central and South America, parts of Spain, and western China.

A possibly apochryphal source suggests that around 440 BC Herodotus described the Macrobians as a culture inhabiting the horn of Africa, at the edge of the known world. The Macrobians as described by Herodotus were fierce warriors and possessed large quantities of gold, to the extent that they used gold instead of iron to bind their slaves. The Macrobians were also famous in the ancient world for their advanced embalming procedures, which involved drying the corpse, covering it with plaster, then painting a likeness of the deceased over the plaster and displaying the likeness within a crystal pillar in the home for approximately one year.

The Han Chinese are credited with chemical preservation starting at about 200 BC. Although extraordinarily well-preserved specimens have been recovered from multiple archeological sites, the methods of preservation are unknown.

Embalming in the cases of these ancient cultures appears to have served religious, aesthetic, psychological, or other cultural purposes, with the main goal being to prolong the human appearance of the corpse for as long as possible. Notably, other cultures, such as those within the Buddhist tradition, or the pre-Christian Norse cultures, attempt to accelerate or circumvent the decomposition process via rapid oxidation of all the body’s tissues – i.e. burning in air or some other method. Many Tibetan Buddhists or Mongols, for example, practice sky burial, wherein the corpse is placed at a mountaintop – a holy place – to be maximally exposed to the elements, and in particular to predatory and scavenger birds, such as vultures. Other traditions, such as Judaism and Baha’i, prescribe burial as soon as possible, with neither embalming nor cremation.

***

The shoulder and arm were next. Deltoides, teres major, teres minor, supraspinatus, infraspinatus, subscapularis, coracobrachialis, biceps brachii, brachioradialis, triceps, anconeus, pronator teres, flexor carpi radialis, palmaris longus, flexor carpi ulnaris, flexor carpi superficialis, supinator, flexor pollicis longus, pronator quadratus, flexor digitorum profundus, extensor carpi ulnaris, extensor digiti minimi, extensor digitorum, extensor carpi radialis longus, extensor carpi radialis brevis, abductor pollicis longus, extensor pollicis brevis, extensor pollicis longus, and extensor indicis were the muscles studied. Nerves included the eighteen terminal branches of the brachial plexus and associated spinal components. Arteries and veins, fascia, ligaments, and joint actions were studied as well, all in order to contribute to our Human Mental Image (HMI).

I suddenly found myself traveled back in time, to a precise moment when I first began working in medical research. In the bathroom while washing my hands I allowed my mind to wander and recalled the scene from The Terminator where Arnold Schwarzenegger as the eponymous android repairs his own arm and eye. I stared down at my arm, watched it flex and extend, watched my fingers move, watched the hinges of the wrist and elbow joints. I recalled the words of Alan Turing:

“A man provided with pencil, paper, and rubber, and subject to strict discipline, is in effect a universal machine.”

***

Herophilos of Chalcedon is credited as the first anatomist known to have performed dissections on humans for scientific purposes. Herophilos lived in Alexandria around 300 BC and wrote nine texts on human anatomy, which were contained in the Library at Alexandria throughout the classical age and which were subsequently lost to fire, the elements – the forces of history.

Galen, a physician from 200 AD, whose anatomical theories dominated Western Medicine for 1300 years, was able to dissect only monkeys and pigs, as dissection of human cadavers was forbidden in the Roman Empire. To formulate his theories on anatomy, Galen relied extensively on the work of Herophilos. Herophilos is known to have conducted dissections in public, and it is claimed by later authors that Herophilos dissected over 600 live prisoners.

It was not until the high middle ages – and especially the renaissance – that the use of techniques for embalming in order to preserve cadavers was conceived as a potential tool for science. It was during this time that renaissance scientists such as Leonardo Da Vinci consolidated the knowledge of human preservation remaining from the ancient world in order to learn about the human body. It is due to well-rounded individuals such as Da Vinci and Vesalius that anatomy and art are so intertwined within Western Civilization.

It was during the Victorian Era, however, that techniques for preservation really came into the modern form, although this again was not principally motivated by science. Because the British Empire covered much of the four corners of the globe, new techniques were needed to prevent corpses from decomposing while being shipped back home or to the nearest colonial outpost for funeral ceremonies.

Likewise, many young soldiers were dying in the American CIvil War. Dr. Thomas Holmes, a graduate of the Columbia University College of Physicians and Surgeons, received a commission from the Army Medical Corps and President Abraham Lincoln to embalm all fallen Union Officers so that their remains could be returned to their families. Later, Holmes’ technique for embalming would be used on Lincoln himself.

***

After learning the back, chest, shoulder, and arms, it was time for a practice practical examination. The goal was to correctly identify as many tagged structures as possible. At two o’clock on a Sunday, twenty-four of the thirty bodies preserved for our class were tagged on one or more structures. More than anything else, the practice practical was an opportunity to appreciate the variation in structures from body to body. It was also a chance to gauge our understanding of the material and assess our own performance in the class.

The first thing on my mind as I walked from cadaver to cadaver was a crushing sense that I was just not cut out for this, that I was somehow in over my head, that I did not realize the level of difficulty and the seriousness of the task I had set out for myself.

The second thing on my mind was all the new faces. I had become used to my cadaver. I could tell from his wrinkles, or I imagined I could at least, that he had lived a happy and fulfilling life. I saw other cadavers which told different stories. A classmate had relayed to me how he believed that perhaps many of the cadavers had donated their bodies to science in an effort to avoid the excessive costs of a modern American funeral. I told him I hoped that that was not the case.

I imagined my father lying on the dissection table, gray and almost unrecognizable, gone from this world, with earthly remains frozen. I imagined myself there, lying dead, with my children looking down at my mutilated body. Was I able to live a good life? Every male cadaver was my father; every female cadaver was my mother. If I focused intently enough on the task at hand, I realized, I could block everything out but the structures I must learn, Indeed, I could ignore the gorilla.

Suddenly it was like a firework of hot pink shooting out from beyond where we all go after we die. Her fingernails. Her nail polish had survived the embalming process, and this humanized her in a profoundly cathartic way. More than anything, what I fear losing is that urgency that envelopes my soul and drives me, that realization that we live in an age of physical and spiritual night.