Autopsy

Life in the trenches with a forensic pathologist in Africa

Ryan Blumenthal

• Publisher: Jonathan Ball
• Year: 2020
• ISBN:
  9781776190195
• Topic: Medizin
• Subtopic: Medizinische Biographien

As a medical detective of the modern world, forensic pathologist Ryan Blumenthal's chief goal is to bring perpetrators to justice. He has performed thousands of autopsies, which have helped bring numerous criminals to book.

In Autopsy he covers the hard lessons learnt as a rookie pathologist, as well as some of the most unusual cases he's encountered. During his career, for example, he has dealt with high-profile deaths, mass disasters, death by lightning and people killed by African wildlife.

Blumenthal takes the reader behind the scenes at the mortuary, describing a typical autopsy and the instruments of the trade. He also shares a few trade secrets, like how to establish when a suicide is more likely to be a homicide.

Even though they cannot speak, the dead have a lot to say – and Blumenthal is there to listen.

1

So you want to be a forensic pathologist?

‘Oh my word, you’re a forensic pathologist? Like in CSI? That must be so interesting! But don’t you get depressed?’

This is a typical reaction I get when someone meets me for the first time and finds out what I do. I never know how best to respond. Do I try to romanticise my job and play to their fantasies? Or do I tell them the cold, hard truth?

The questions do not stop there. People usually hang around at the cocktail party or the braai, wanting all the curious details. The first question people usually ask is, ‘What is the most interesting thing you have seen?’

At this point I stop them and say, ‘I do not find other people’s unnatural deaths interesting!’ After all, each of the unnatural deaths I deal with represents a tragedy in someone’s life. However, if you were to ask me what the most unusual or strangest thing is that I have seen, I would probably tell you the story of the giant rat.

One day, a body arrived at the mortuary. It was sealed in a metal coffin, which in turn was placed in a wooden coffin, fastened shut with steel screws. The inside of the metal coffin was filled with 100 per cent formalin.

This was quite typical: when bodies from any of the central African countries are referred to us for a forensic autopsy examination, they are never placed in 10 per cent formalin as per best-practice occupational health and safety guidelines. Nope – it is almost always 100 per cent formalin, which means that, should you open the metal coffin indoors, you’d get very sick or die from asphyxia: the formalin would volatilise and turn the space into a gas chamber.

So, we took the coffin outdoors, removed the metal screws and poured the formalin into large metal drums for formal waste disposal. We then rinsed the contaminated body with a hosepipe.

The next moment we noticed a piece of ‘wire’ protruding from the region of the xiphisternum, the area below the chest plate. The deceased, a South African, had died in a plane crash in central Africa. At first, we thought the ‘wire’ could be part of the plane wreckage. But you can never be too safe, so we immediately had the body X-rayed. After all, it could also have been part of a bomb. Certain nefarious groups have been known to place bombs inside dead bodies to injure and even kill health professionals.

What we found was most extraordinary. It was not a bomb – it was the decomposing body of a giant rat, trapped in foetal position inside the thorax of the deceased! The rat was almost the size of the greater cane rat, which lives in reedbeds and on riverbanks in sub-Saharan Africa. Heaven knows what it was doing in the dead body.

During the embalming process, the mammal must have entered the thorax during post-mortem predation and was most likely enclosed in the thoracic cavity by post-mortem swelling of the body. Only the rat’s tail – which looked exactly like a piece of wire – protruded from the body.

Other questions I am regularly asked include, What is the worst thing you have seen? The worst smell? What constitutes a good death … and a bad death? I am also asked, What information can be gleaned from someone’s medicine cabinet? (Quite a lot.) What is the perfect murder? How can we prevent suicide? People also ask me to tell them about prison, because I also have to attend deaths in custody.

In this book I will try to answer these, and many other, questions. Take, for example, the average medicine cabinet. It will show you what medication someone is taking and if they suffer from any serious diseases, whether they use mouthwash and even if they floss regularly. Should you discover hundreds of vitamin supplements and/or omega oils, the medicine cabinet could also tell you whether someone is a hypochondriac.

The antiretroviral tablets used to help manage HIV/Aids will also generally be kept in the medicine cabinet. I once went to a scene of a dyadic death (a murder–suicide). The husband had shot and killed his wife, and then himself. Examination of the open medicine cabinet showed a container of antiretroviral drugs; some were also present on a nearby table. My theory is that either the husband did not know that his wife was on antiretrovirals and found out when he saw the pills, or he knew they both had HIV/Aids and may have killed his wife and himself for this reason. Sadly, the answer will never be known.

Most of the suicide and dyadic death cases I have seen had a background history of HIV/Aids. This, I believe, is due to poor initial counselling. If only people knew and understood that HIV/Aids can be treated like any other chronic natural disease (such as hypertension and diabetes mellitus). Most people die with their HIV and not because of it. This was a really tragic case. Of course, my theories are merely speculation. Most other cases of dyadic deaths were shown to be due to love triangles.

Another question I’m frequently asked is, What is the quickest and the most painless way to die? I usually answer by saying, Please try to focus on life. But to answer this somewhat morbid question: personally, I would like to die in the arms of a woman, slightly drunk, slightly in love and due to a massive myocardial infarction. That should be a relatively quick and painless death.

Failing that, I think a nuclear death, or a lightning death, or jumping into an active volcano would probably be the quickest death to endure. Another swift way to die would be assassination by a sniper. Not just any sniper, but a really good sniper with a really good rifle and a high-velocity, large-calibre projectile, from behind the head. On a balance of probabilities, this would probably be the ultimate way to go.

Paradoxically, a guillotine or a gunshot wound through the temples of the head with a low-velocity weapon would be a relatively slow death in comparison. With a guillotine, for example, the blood might pump through the vessels in your neck at about 70 ml of blood per pump for the next thirty or so minutes. Unless the projectile goes through the brainstem, it won’t be a rapid death. (There is a cubic centimetre of brain tissue in the brainstem where your vasomotor and cardiorespiratory centres are located.) Aiming for the brainstem would ensure a relatively quick and painless death – you would drop to the ground like a sack of potatoes.

There are many cases of botched suicides where people who tried to shoot themselves through the temples merely took out their eyes and went blind. There are also cases where people who shot themselves through the roof of the mouth and out the frontal lobes of the brain have opened the front door for the paramedics. Then, I know of an individual who had been stabbed in the heart yet managed to kill someone before finally succumbing to his heart injury.

On the flip side, in certain cultures in South Africa people actually wish for a slow, drawn-out death, since they want to have time to say goodbye to all their loved ones and friends before they die.

What is death? Death is an unavoidable change which occurs in everybody’s life. It is feared by many, but welcomed by others. If you are terminally ill, you may welcome death. If you are young and mighty, death is a foe.1 Death has also been described as one of man’s greatest and most exciting experiences.2

Death and the process of dying are characterised by loss of function of the great organ systems (the cardiovascular, respiratory and nervous systems) and their coordination. This reveals a dissociation of the function of the different organs. The agonal period may be initiated either by disease or by trauma. The period of dying is called ‘agony’ and its duration can vary depending on the damaging agent and the remaining facilities of the patient.

The final crisis leads to a state of vita minima (state of apparent death) in which no vital signs are apparent, and to a state of death characterised by irreversible cessation of circulation or by respiratory arrest. Under special clinical conditions, brain death may replace the classic signs of death – that is, irreversible circulatory or respiratory arrest and its consequences.3

The medical practitioner in general practice, or a specialist, is expected to establish whether death has occurred or not. At times, the diagnosis of death may be extremely difficult; often, even the most experienced practitioners are fooled because so-called death mimics can occur.

Once, an elderly woman whose normal bodily functions had apparently ceased was admitted to the hospital at which I was working. I could hardly hear her heartbeat, there was no respiration and her temperature was hypothermic – that is, well below normal. Fearing the worst, I immediately covered her with a space blanket, gave her oxygen and inserted an intravenous line in a collapsed vein in her arm. I went to speak to her family and told them that I did not expect their granny to survive for much longer. To my very great surprise, when I returned to her ward she was sitting up, listening to the radio and eating crisps! Hypothermia is a very good death mimic, and I was badly fooled.

There are many ways to die, but it is important to distinguish between natural and unnatural deaths. Depending on which agencies’ data you review, South Africa has between 300 000 and 600 000 natural deaths per year, with an average of approximately 500 000 per year. These encompass deaths from heart attacks to strokes to cancer, for example. Those who die in this way will generally not undergo a forensic autopsy but may undergo a hospital autopsy performed by an anatomical pathologist, especially where the death is due to natural causes but the natural disease is unknown. The deceased’s family would have to consent to an anatomical pathology autopsy.

Forensic pathologists perform autopsies on unnatural deaths only. Altogether, there are approximately 60 000 to 80 000 unnatural deaths per year in South Africa, with an average of 70 000 per year. An unnatural death may be defined as:

•a death caused by the application of a force or any other physical or chemical factor, direct or indirect, and with or without complications

•any death which, in the medical practitioner’s opinion, was caused by an act or an omission on somebody’s part

•a death in terms of section 56 of the Health Professions Act (Act 56 of 1974), which states that ‘[t]he death of a person whilst under the influence of a general anaesthetic or local anaesthetic, or of which the administration of an anaesthetic has been a contributory cause, shall not be deemed to be a death from natural causes’, these are also known as procedure-related or procedure-associated deaths

•any unattended, unexplained, suspicious or sudden unexpected death.

The medicolegal investigation of death in South Africa has a very strict legislative framework. The field is highly regulated; many Acts legislate it, such as the Inquests Act (Act 58 of 1959); the Registration of Births and Deaths Act (Act 51 of 1992); the National Health Act (Act 61 of 2003); the Health Professions Act (Act 56 of 1974); and the Criminal Procedure Act (Act 51 of 1977). There is also the National Co...