Seeing inside dead bodies
People think they know about forensic pathologists through the many representations in drama. But there's another kind of pathologist that does an important but often quite gruesome job, writes Pippa Stephens.
Every day Dr Simi George opens up several corpses to try and find out why they died.
She sees dead people's hearts, their eyes, their ribcages and the inside of their skulls in her job as a histopathologist at St Thomas's Hospital in London.
Sometimes the cadavers are so decomposed she can't see their face, their skull is black and there are maggots. She can struggle to find the cause of death.
Pathologists find out the medical cause of death - with forensic pathologists working if there's a criminal aspect to the death.
George, 41, also works on children who have died, stillborn babies and mothers who have died in childbirth.
She performs autopsies on up to 50 bodies a week brought in from coroners and hospitals. They are done either with the relatives' consent or under coroners' orders, when doctors don't know what the cause of death is and the patient satisfies one or more of about 20 criteria.
The mother-of-two is almost totally unflappable about the mechanics of her job. "I don't mind maggots, or decomposed bodies, or urine, or poo, but the vomit - the stomach contents - that gets to me," she says.
She has never once been sick, even when she was training, and has continued working since, even through morning sickness.
While she performs a post-mortem examination on a 65-year-old woman - who had died in hospital five days earlier - and is looking for clots in the woman's heart, the smell is nauseating.
Forensic pathologists and histopathologists work separately in adult cases, but George says with children it is protocol to have both present, meaning she has been exposed to cases she wouldn't see in adults, often involving violence.
After people die, their bodies are brought into the mortuary and kept refrigerated at 4C. They lie naked on a table during the autopsy. In some cases the eyes are open, when they tend to have a yellow hue and a slightly crystalline appearance. Sometimes under the corpses small puddles of fluid collect.
If the person died recently, the skin is pale, with a blue tinge, and looks marbled across the chest and shoulders.
Without the pumping of the heart, blood is dragged down by gravity and pools in areas closest to the floor.
Tracey Biggs, a service manager at St Thomas's, is also an anatomical pathology technician. Part of her job involves opening up the body and removing the organs.
Sometimes the abdomen is green, she says, as gut bacteria kick-start the decomposition of the body.
Bodies smell differently depending on why they died, says Biggs. She said the smell changes if someone has spent a long time in intensive care, on courses of drugs. And decomposed bodies often have a "sweet, cheesy" smell.
When are post-mortem examinations done?
- Forensic post-mortem examinations are requested by a coroner when a cause of death with a criminal aspect is suspected
- Consented post-mortem examinations are requested by a doctor with permission from relatives, when it is felt that the examination could reveal useful medical information such as insight into inherited problems
- Consented post-mortem examinations used to be the norm, but numbers have dropped dramatically
- Practitioners say the drop in consented examinations is huge loss to medical science
- More than 30% of death certificates are currently wrong, according to an estimate
To remove the organs, Biggs first makes an incision down the front of the body and takes out the breastbone and opens up the rib cage. Then she removes the heart, lungs, neck structure, intestine, liver, spleen, kidneys, bladder and uterus, or prostate.
Last of all, she cuts around the "halo" of the skull with a scalpel, peels the skin forward down the face, to the level of the eyebrow, and down at the back of the head. Then, after using a special saw, a skull key and a mallet are used to free the skull and remove the brain.
"This part tends to be the most distressing for people watching," she says. "The first time I saw a brain, it was surreal, fascinating - something you can't ever imagine."
She says she learned techniques during training, like lifting the skin up on the stomach when slicing it open to avoid nicking the bowel - in order to help keep the organs intact.
When George inspects the organs, she looks for tumours, which can be yellow, white, red or brown, while a honeycomb texture on the cut surface of the lungs may indicate emphysema, or lung disease. And meningitis can cause a heavier, yellow brain.
If an autopsy is inconclusive, doctors analyse samples of the body's tissue using microscopes, then, if unsuccessful, toxicology labs look for signs of an overdose.
With the permission of the family, information from people who die in hospital can be sent on for medical research, in the case of an unusual genetic disease, for example, says George.
Stoic philosophers, such as the Emperor Marcus Aurelius, said we should think about death on a daily basis, to be fearless and dignified when it happens - and to concentrate on the here and now.
But perhaps it isn't that easy.
Biggs says: "Every day, we see how easy it is for life to end. We become aware.
"I am scared of death. And I'm scared of losing people close to me. I don't take risks - I won't even go on a roller coaster ride in case I have a heart attack," she adds.
In contrast, George says she is not scared as there is "nothing you can do". "Death is not taboo - it is part of life and you shouldn't be shying away from discussing it."
Their work provides a window into society. Each week in winter, George and her team see one heavily decomposed body from a person dying alone in their house and not being found. There's also one suicide case per week.
The mortuary covers two out of 32 boroughs in London.
George is worried about whether her profession will continue to exist in the way it does now.
She only sees about one or two "consented" adult cases - where the next of kin have chosen to give permission, as opposed to the post-mortem examination being mandated - out of about 100 a month. Situations such as the Alder Hey organs scandal in Liverpool, where unauthorised organs were kept, have hurt the profession's reputation, she says.
But these "consented" autopsies are vital. Up to 33% of death certificates are estimated to not list the correct cause of death, so the government may not be funding the right areas of research, George says. The theory is that if more autopsies were carried out, the real cause of death would be much more likely to be found.
Pathologists want to examine people who died of long-term illnesses such as cancer to see if the treatments are working, she says.
And post-mortem examinations flag up genetic diseases, so doctors can help the family if they are at risk.
"I really, really hope the public realise we are not these people that keep babies' hearts in jars," says George. "Aside from satisfying relatives' minds about the cause of death, post-mortems help medical professionals to learn more about diseases and the evolution of diseases to benefit the rest of the public. We want to help."
She says she treats the corpses the way she would want a loved one to be treated - with care and respect.
But George says her job has made her braver as she sees so much "wasted life" through premature death.
"You have only got one life. You have got to live it," she says.
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