The moment the door opened, the mildly unsettling smell of hospital antiseptic was displaced by the more unsettling, though more familiar, mixture of formaldehyde and tissue going bad, l’arome de la morgue. Inside, Joey’s graying body lay faceup on the metal table, naked and pitifully vulnerable under glaring fluorescent light fixtures. Above the foot of the table hung the usual meat-market scale, shocking in its ordinariness, in which his internal organs would be weighed. A tall, somber, long-limbed Indian man, the diener-the autopsy assistant-was finishing up his tasks of preparing the body and the instruments, and taking the preliminary measurements and photographs.
“We are all ready, Doctor,” he said on seeing Merrill.
“Hello, Rajiv. X-rays?”
“Yes, Doctor. The physician from St. Mary’s sent them.” Rajiv nodded toward the wall-mounted viewing box, to which four X-ray plates had been clipped. Merrill walked to the box and, leaning over, peered briefly at the indistinct images. “Fractured spinous processes on these upper thoracic vertebrae, you see?” he said, pointing. “Some damage to the sacroiliac region as well. Both perfectly consistent with a fall onto his back, wouldn’t you say?”
Gideon nodded and placed a finger on a photograph of the left arm. “And I think the olecranon is broken, too; that’d go along with it as well.”
“Yes, I believe you’re right. The cranial photos are ambiguous, though, but then who can read a cranial X-ray? There’s damage to the head, all right, inside and out, but hard to tell exactly what kind.” Merrill straightened up, his eyes alight and already straying toward the saws and knives that Rajiv had set up on a small rolling table. “May as well have a look at the real thing, shall we?”
“May as well,” Gideon said forlornly.
“Well, let’s cover him up, Rajiv,” Merrill said.
“Cover him up?”
“For decency’s sake.”
“Decency’s sake?”
“Yes, we’ll start at the top-”
The top? Gideon said to himself.
Rajiv didn’t disappoint him. “The top?”
“Yes, the top. Dr. Oliver will be most interested in the skull, I believe, so let’s begin there. In the meantime, let’s drape him from the neck down, why don’t we?”
Rajiv was obviously dubious about the correctness of this-pathologists generally began with the trunk; the famous Y-incision-but he did as he was told without even a murmured “Drape him?”, pulling a sheet neatly, even tenderly, up over Joey’s body. Clearly, understanding that Gideon had known Joey, Merrill had had this done out of sensitivity for his feelings, and Gideon very much appreciated it. It was, for whatever reason, easier-less of a violation, less defiling-to open up Joey’s head with the rest of him covered up.
Rajiv handed both men plastic “bouffant-style” operating room caps, which they slipped on over their hair. Gideon was grateful that Clapper wasn’t there to see him.
“You didn’t want gloves, did you?” asked Merrill, who was partial to doing his dissecting bare-handed. “When I’m working with tissue, I find the sense of touch in my bare hands extremely sensitive,” he had once told Gideon-who much preferred gloves, and for exactly the same reason.
“Gloves?” Gideon said now, as if they were the furthest thought from his mind. “No, of course not.” With luck, he wouldn’t have to touch anything.
Many pathologists had their dieners do the gross cutting-the Y-incision, and the ear-to-ear over-the-top-of-the-head incision to get at the skull-but not Merrill, of course. He preferred to do it all himself, so once Rajiv had placed a support block under the back of Joey’s head and turned on the hanging microphone to record their observations, the diener stepped away from the table, awaiting further instructions.
“Well, let’s see what we have,” Merrill said happily. Gideon half expected him to rub his hands together, but with his arms remaining folded, he peered long and hard at Joey’s head. “What do you think?”
Until that moment, Gideon hadn’t looked directly at Joey’s face, but now he did. It helped, he found, that Joey didn’t look much like Joey anymore. In addition to the puffiness and distortion that went with death from cranial blunt-force trauma, on his face had blossomed a pair of bilateral periorbital hematomas-spectacular, purplish, shiny black eyes, which were known in the trade as “raccoon eyes,” and for good reason. Huge and round, blackening both his upper and lower eyelids, swelling them closed, and as dark as stage makeup, they made it look as if he were wearing a strange, pale face mask with black holes cut out for the eyes. His hair, so colorless and fine to begin with, had been rinsed by Rajiv under the faucet at one end of the autopsy table and was still damp, so that it seemed limper and sadder than ever. High on the back of his head, about two inches up from the part of the scalp overlying what anthropologists called “lambda”-the Y-shaped juncture where the two parietals meet the occipital bone-a circular area three or four inches in diameter had been shaved, the better to show a gaping, star-shaped laceration where his scalp had split open.
“You’re the pathologist,” Gideon answered. “What do you think?”
“I think we’re looking at a pretty obvious case of blunt-force trauma to the posterior parietal region, which, of course, goes along with the injuries on the radiograph.” He added a few observations for the microphone and pressed gently against Joey’s cheeks and temples. “No indications of superficial damage around the eyes, and the craniofacial skeleton seems undamaged. I expect we’ll find that the orbital hematomas are not distinct injuries, but a result of the parietal trauma, the force having been transmitted by the brain.”
Gideon nodded. “Contrecoup.”
“Contrecoup,” Merrill agreed.
They were talking about one of the most intriguing and least understood aspects of damage to the human skull and brain: the distinction between coup and contrecoup injuries. Generally speaking, when a moving object hit a stationary head-a blow with a hammer, say-the injury to the brain was going to be directly under the impact point. Whack a man hard enough on the occipital bone at the back of the head, and it will almost always be the occipital lobe of the brain that gets pulped. That was a “coup” injury. But when things were reversed, when a moving head hit a stationary object-in a fall, for example-the brain injury was likely to be at the opposite pole of the brain. Let a man fall off a catwalk onto stone paving and land on that same, rearward occipital bone, for example, and it would be the frontal lobe of the brain that got mashed into red jelly: a “contrecoup” injury.
Why this should be had puzzled scientists for centuries. In 1766 the Royal Academy of Surgeons in Paris had offered a prize for a definitive explanation of contrecoup. They didn’t get one then, and they still didn’t have one that satisfied everybody. Gideon, no expert on the brain, was willing to accept the common theory that, in a fall, the skull is traveling faster than the brain that is cradled inside it, so that when the back of the head hits the ground the brain continues to move, subjecting it to a piling-up of impact forces at the front.
Whether that was really the way it worked or not, contrecoup injuries were a fact, and he agreed with Merrill that they were looking at one now.
“Well!” exclaimed Merrill, and now he really did rub his hands together. “Let’s get on with it!” He stuck out a hand, into which Rajiv slapped the scalpel that he had waiting. Gideon moved a discreet step back. Rajiv, who was already wearing surgical gloves, now pulled up the mask that had been loosely tied around his neck.
Merrill, maskless and gloveless-contrary to both forensic and hygienic protocol-was a quick, sure worker, with no wasted movement. One hand, on Joey’s forehead, steadied his head against the block, while the other placed the scalpel blade behind the left ear. A moment’s pause to align the blade to the path that was to be followed, and the scalpel was deftly whipped over the top of the head, well in front of the scalp wound, and around to the back of the other ear: the standard coronal mastoid incision to expose the skull. With Joey dead so long, there was very little blood, but all the same Gideon’s stomach contracted, almost as if he could feel the blade slicing through his own scalp. This was at least the twentieth autopsy at which he’d been present, and before them he’d dissected two corpses in gross anatomy in graduate school, yet it was always the same. Would he never get used to them?