The decedent is a 72yo WF with hx of hypertension, found decomposing in her locked apartment. Neighbors noted a foul odor, and the building super, who had not seen her for several days, opened the apartment for a wellness check. She was seen lying supine amid hoarder materials and trash on the floor in her unkempt apartment. EMS pronounced without resuscitative efforts. Prescription anti-hypertensive medication noted. No drug paraphernalia or alcohol at scene. Cigarettes and ashtrays present. No known next-of-kin; will try to locate before referral for city burial. Identified by building super despite decomposition.
How can this happen, you might ask? Was this woman invisible? How did the last fiber of her life’s rope fray and split with no one’s awareness? While I do not know or understand how, it is a scenario repeated on a daily basis, with minor variations, throughout the city that is my home. It has led me to muse on the degree of disconnection that seems to be at the heart of our world’s problems.
“Morbid anatomy” is the old-fashioned term for “pathology”, the study of organs and tissues in disease (literally, “the study of suffering”). As a forensic neuropathologist, it is my job to examine the brains of individuals who have met an unwitnessed, violent, or otherwise suspicious death, and to assist the medical examiner performing the complete autopsy as they formulate the anatomic cause of death (in the above scenario, it was a hypertensive brain hemorrhage – a stroke), and the manner of death (here, natural). We are part of a large cohesive network of forensic biologists, toxicologists, medicolegal investigators, police detectives, and scientists and technologists of all stripes, united in the cause of truth-seeking. Our agency motto is “Science Serving Justice”.
However, what we do, together, is as much art as science. The work requires a degree of humanism and fortitude that, in my opinion as someone who trained and practiced for 3 decades on the hospital side of medicine, is not appreciated adequately by society, who attributes greater compassion to caretakers of the living. We are caretakers of the dying.
To care for the dying is a process extending beyond the last breath. The breaking down of the body, the dissemination of the belongings, the dispersal of the friends and family held together by this person – they are also part of the dying. And in situations as in the above illustration, when a person dies alone – disconnected - we are the ones who try to complete the process for them. We can only do this by compassionately viewing their final situation in the light of our expertise, while drawing on our own personal experience.
This woman easily could have been my mother. Struggling with cardiovascular disease, diabetes, respiratory illness from smoking, and the beginnings of dementia, my beautiful, brilliant, and multi-talented mother became more and more isolated. She had taken early retirement, which meant she lived in poverty on a miniscule Social Security check. She couldn’t go to lunch with her upper middle class friends anymore. She stopped singing in her church choir. She had her 2 dogs put to sleep without telling any of us. She started going to rummage and yard sales, acquiring an astounding number of things she didn’t need. My four siblings and I knew we had to do something, but it literally took us years to convince her to move 70 miles away to be near one of us. (Did I mention she was stubborn?) We quickly realized her hoarder tendencies, and when my sisters and I tried to edit her things as we packed for the move, she actually said “But ‘things’ are all I have”. A child of the Great Depression, every little piece of string or remnant of soap was kept for potential later use. Deconstructing her hoard was a monumental task. The stress of the moving day landed her, that very night, in the hospital, where she went on to get a quadruple bypass. While she never fully recovered, she at least was in care when she died the following year.
“Things are all I have.” Those words haunt me. Had I as her eldest daughter, pursuing an academic medical career in Boston, far away from her in Ohio, not shown her enough love? I had orchestrated family vacations with her, taken her on trips - I even bought the condo in Columbus she never got to occupy fully. But what I could not give her was my constant physical presence. And as a busy physician trying also to “have a life”, I am not very good at calling my family. Disconnection.
The decedent is a 24yo AM, found hanging by housekeeping staff in a midtown hotel room. A climbing-type nylon rope was around his neck, and was secured to the clothes-hanging rod in the closet. A Chinese passport, local community college ID card, and suicide note (vouchered for evidence) were on the bed. According to the agency’s translator, his note describes having a difficult time with classwork and with making friends after having moved here 4 months ago. Next-of-kin are in China, and consulate will make contact.
In such a scenario, we examine the body to exclude some unknown illness (such as a tumor or infection affecting the nervous system that might alter one’s behavior), as well as evidence of foul play or drugs. Overwhelmingly, though, in such cases the cause and manner of death are easily determined: hanging by the neck; suicide. The more compelling and unanswerable question is, why?
We all have such high hopes for our lives, and for the lives of our loved ones. “Dream big”, we may be told from a young age. “Commit yourself!” “Go out on that limb!” “Your father has worked for years so you can have a better life!” Or, the only thing worse: “You’ll never amount to anything.” “Loser!” “No one cares about you.” Then, our hopes take on an even more desperate dimension of pure survival, akin to an animal in the wild.
And yet, animals in the wild do not kill themselves. Just the opposite - instead they will chew their own limb off to survive being caught in a leghold trap. How is it that we can consciously choose to bring about our own death? If one has never felt the lure of suicide, it is difficult to understand. My mother used to say, “Suicide is a permanent solution to a temporary problem.” I was never able quite to accept that formulation. I offer my own experience with depression and suicidal ideation: it is most simply a way to escape from excruciating pain, which, after it goes on long enough, starts to feel permanent. And splintered dreams and broken hearts create excruciating pain.
The summer I finally began dating after my traumatic divorce, I fell instantly in love with a handsome, charismatic artist. We rode bikes in the cemetery, kissed beside the mausoleums, drank wine and watched a young cardinal fledge its nest in my lush back yard. The next day I saw the little fledgling, twisted and stiff, with ants where its eyes used to be, in the grass far from its nest. I gently picked it up and reverently laid it out for my mourning, knowing full well its larger meaning. My artist lover moved to the West Coast in the fall. My heart felt broken all over again.
Our lives are a series of fledges, each with its risks for failure. Aside from our essential fortitude (a product of both nature and nurture), we rely on the safety net of love and connection that we weave with one another. Stretched by distance and hardship, this net may not always hold. We may be unable to endure the pain of separation, disappointment, the shattering of dreams large and small. The human soul can withstand only so much disconnection. And phone calls, texts, virtual electronic facetime can substitute only so much.
The decedent is a 29yo WM with a history of autism and seizure disorder, found at 0800 by his family face down in bed. No alcohol or drugs, drug paraphernalia, suicide note, or other suspicious circumstances noted. He was last seen by his father at 2330 the previous night, playing video games on his computer, which he spent most waking hours doing. He did not attend school and was unemployed (he was nonverbal and very anxious in social settings). Medications included anticonvulsants, and the pill counts were appropriate. His last seizure (tonic-clonic type) was one week ago.
The challenge of understanding autism, now among the most common diagnoses made in medicine, affects us all. Where did this epidemic come from? Is it (as some assert, despite no scientific evidence) because of vaccinations? Cell phones? Cosmic radiation? Chemicals in our food? Are we just more aware of it than we used to be (“ascertainment bias”)? Whatever the reason, autism spectrum disorder is a disease of disconnection, apparently at a neural level.
The fact that 50% of individuals with autism have seizure disorder (or epilepsy, an equivalent medical term that to some may have a pejorative ring) lends support to the idea of a primary neural defect. In experimental animal models of autism, abnormalities in “mirror neurons” have been found. These are a cell type in the brain that mediates the ability to imitate our parents and family members as a means of learning survival skills., may help us comprehend, at least in part, the deficit among persons on the autism spectrum. Could those on the autism spectrum lack this neural capability, becoming overwhelmed and disadvantaged by the challenge of attuning to others and modeling their behavior in the usual ways?
Among animal societies, attunement is key to survival: school swimming in fish, swarming in bees, coordinated flight among starlings. If an individual cannot participate in social engagement, they may suffer from selection bias, starve or become prey. Without attunement, we become disconnected.
The decedent is estimated to be in his 30s, possibly of Hispanic ancestry, apparently undomiciled, found on a park bench in Central Park. He is unkempt/dirty, very thin, with headlice. Missing one shoe, the left foot is wrapped in newspapers and brown paper bags, around an oozing wound on the heel. He is inappropriately dressed for summer weather (2 jackets; 1 wool). Contents of pocket: Michigan driver’s license (expired 8 months ago), prescription for antipsychotic medicines from 1 month ago, receipt for malt liquor from nearby deli dated from the day before. Homeless Services will be contacted in attempt to identify him and his next of kin.
Our bodies are our homes. And yet we still require shelter from the elements, from dangers of all kinds. For us to flourish in the world, we depend on others – to launch us in life with education and opportunities, to employ us based on our skills, to tend to us when we are sick. Physical illness challenges all of us from infancy, while mental illness, such as depression, schizophrenia, or anxiety disorder, to name just a few, affects at least 20% of us during our lives, often beginning in early adult life. But to be mentally ill and without support is to be cast adrift on turbulent waters in a leaky raft – how long can we hang on before we are swept overboard? Before untreated conditions, abusive self-medication, and the weight of loss become too much to endure?
I recall times in my life of few material resources, of being floated by family, and, when finally on my own, of living meagerly on peanut butter and rice. But I was never truly at risk of homelessness. I have had, though, more than a few friends, including some with serious mental illness and substance abuse issues, face this rock-bottom reality. There is only a thin safety net beneath any of us. It is so hard, an existential crisis, really, to know how to help them.
My grandparents used to tell us of when, shortly after the Great Depression and into the era of World War II, various cousins and maiden aunts lived with them, in their tiny shotgun house in Louisville, Kentucky, sometimes for years on end. I have dear memories of some of these old great aunts and second or third cousins. To leave a family member on the streets was simply not done. My grandmother used to say “We were poor, but we didn’t KNOW we were poor.” And sharing everything one had, without expectation of return, was just normal.
There are no homeless birds, or so the Bible says (Luke 9:58). And the lilies of the field, “they toil not, neither do they spin” (Luke 12:22). The assumption is that God provides for all. Except when He doesn’t. Then we must provide for each other. This requires a tradition of connection, both familial and societal. The casualties of this disconnection are seen in my work every single day, and break my heart every single day.
The decedent is an 8-month-old infant, brought in by EMS after a call at 1925 from mother’s boyfriend that the child started “vomiting while being fed”. Boyfriend had been left with the infant at 1400 when mother went to work as second-shift nurse’s aid in nursing home. ED personnel noted bruising of left ear and beneath chin, and on extremities in a concerning pattern. Retinal hemorrhages were documented by ophthalmologist in ED. Head CT shows subdural blood over cerebral convexities. Police and child protective services notified. Two other young children in household.
These are truly the most dreadful cases. How, one asks, can anyone harm a child, a helpless baby? In some animal groups, overpopulation and scarcity of resources lead to mass suicide, homosexual behavior, or eating of young. Eagles will kill the weaker of two nestlings, to allow the stronger the better chance to survive. But that scenario, while disturbing, is at least “rational” in a Darwinian sense.
Maya Angelou, the great poet, said “We are all human; therefore, nothing human can be alien to us.” As a Buddhist, I have tried in my practice to feel compassion for an adult who embodies so much rage, frustration, sense of powerlessness or insecurity, that they relinquish all perspective around their actions. When pushed to our limit, we all have said hateful, harmful things, and some of us may have acted out in hurtful ways. Can we understand the emotional state of a fellow human being driven to this extreme, lacking the skills to handle these dangerous emotions? Can we forgive, educate, and prevent such tragedies?
As one whose chosen profession is the study of suffering, I do not have the answers. But I do feel that, as long as we continue to be so profoundly disconnected from one another, the morbid anatomy of our sad human frailties will be our legacy.