6

I was almost thirty before I performed my first post-mortem. There had been the usual house jobs in different departments around the hospital, from surgery to gynaecology, from dermatology to psychiatry. Only when these were completed as 1980 ended did I begin to focus on my goal. It was more than ten years since I’d started medical school and I hadn’t even reached the first rung of the ladder to becoming a forensic pathologist, which was to qualify as a histo- (or hospital) pathologist.

In general, pathology is a science that enables us to understand disease by studying it in micro-detail: we name it, find how it is caused, learn how it progresses. Everyone has some sort of contact with a path lab without really being aware of it: all urine and blood samples are sent there, for instance. Of course, staring at so many samples in such minute detail is not glamorous work and, unsurprisingly, the pathology department is always somewhere at the back of the hospital, far away from patients.

Qualifying as a hospital pathologist involves spending a huge amount of time looking at microscope slides, studying both normal and diseased tissue. I have lost count of the hours I spent peering at, for instance, cancerous cells.

I found all this very tedious because I knew that, when I actually reached my goal and became a forensic pathologist, I’d be referring such slides to specialists and seldom looking at them myself. But I had to study this now. There are many pathologists who will carry out post-mortems, if death is believed to have occurred naturally, to establish the exact cause and this would be the next part of my training – because how could I examine suspicious, unexplained deaths and view them forensically if I couldn’t recognize natural causes?

So, there was nothing of the criminal in my first post-mortem. The patient had died at St George’s, Tooting, and the case had been chosen specially for me because it was considered straightforward.

I knew I would be surrounded by senior colleagues and helpful mortuary staff but nevertheless the butterflies in my stomach as I went to work reminded me of my first day at school. Handfuls of rain banged against the bus windows and then ran down them, blurring the world outside, and I longed for the day when I could afford a good pair of shoes which would keep my feet dry and a good coat to keep me warm. I sat huddled upstairs at the front of the bus as it rattled and swayed to Tooting Broadway. I tried to distract myself by rereading, yet again, the medical notes of the deceased. I’d been given them the day before, discussed them with the more senior trainees and almost knew them by heart already.

I had watched quite a few post-mortems at the mortuary and had half anticipated, half dreaded the time when it would be my turn to take up the scalpel here. Like the first Anatomy class, it was a test – no fainting, blanching or vomiting allowed. Not because this would mean the end of my career, but because I knew my colleagues would never let me forget it. The same was true of mistakes. The others would correct me – and then tease me about it endlessly. And I really did want to do well. No cutting my fingers instead of the patient, no making holes in critical organs, no slicing the bowel by mistake. I wanted clean cuts, decisive exposure of the relevant organs, correct note-taking, accurate diagnosis. Plus, a bit of luck. Oh, and a lot of courage.

Most people recoil at the smell of the mortuary. I’d say now that mortuaries don’t smell at all, but it may be that I’m just used to it. Certainly, in those days it seemed to me that the nose was assaulted by the whiff of formalin, a smell as acrid as broken branches: perhaps holly in winter or an elder bush snapped in summer. But far more penetrating.

The first sound heard on entering a mortuary is the rise and fall of almost unfailingly friendly voices. And, believe it or not, often those voices may be laughing, as in any office or workplace in the land. In fact, if undertakers are coming and going, I think the word is banter, although I have never heard jokes at the expense of the dead. In my experience, they are always treated with the greatest respect.

The dead’s entrance is unseen by the public. It is usually next to a neat, bright office where arrivals are carefully, no, meticulously booked in and then taken down well-lit corridors to the banks of fridges, ten or fifteen of them, in a solid line.

The fridges are a few metres high. Inside, each has shelving for about six bodies. The dead slide on their trays from their metal trolleys onto their shelf. Clang. The door is shut. Whoomp. The trolley is parked, ready for its next use. Clatter. That is the sound of the mortuary. Clang, whoomp, clatter.

I already knew these sounds and smells well. In fact, mortuaries were just beginning to feel like home. But I can’t pretend that today this familiarity brought any comfort.

‘Cup of tea, Dick?’ offered a kind assistant. I couldn’t even answer him, let alone drink it.

The other mortuary staff were determined to treat my rite of passage as a joke.

‘Er, Dick, make sure you get the right body, would you?’

Etc., etc. I tried to laugh but risus sardonicus – the grim, fixed smile of strychnine poisoning – seemed to have set in.

I emerged from the changing room in my scrubs and found mortuary wellies. They were a deathly white, which, that day, perfectly matched my face. I wore a pair of bright yellow Marigold gloves and an apron. The kit has changed a lot over the years but then the apron was something akin to the aprons worn in abattoirs and butchers’ shops. The gloves were no doubt cheap and good for washing dishes, but they protected you only from germs, not cuts.

‘And, remember, Dick, those gloves also show you where your fingers are …’ were the final words of helpful advice from the staff as I passed the fridges and entered the post-mortem room.

The patient was a middle-aged woman who had been admitted to the hospital with severe chest pains and had then died on the coronary care unit some days later. The mortuary staff had her waiting for me on a porcelain table. She was still wearing her shroud. Wrapping bodies really neatly in tight sheets used to be one of the great nursing skills, like making a bed with hospital corners, but it is seldom if ever seen now. It gave respect to the dead but exasperated the nurses: it could take them an hour or so to shroud a body well, only for us to simply pull the sheet off in the mortuary to perform the post-mortem. No wonder busy ward staff abandoned all that linen origami and started using simple paper shrouds instead.

The mortuary staff removed the shroud to reveal the body.

I stared at her. Anatomy dissection had been one thing, with its dead bodies so long pickled and grey that it was possible to forget they had ever been alive at all. But this was quite another thing. Here was a fresh body. Here was a woman who, within the last twenty-four hours, was living and breathing and talking to her family and to her doctors. According to her notes, she had said she was determined to get better and go to her granddaughter’s wedding in a month’s time. And then was dead within the hour.

In fact, she looked really rather healthy and not very dead at all. I had the uncanny feeling that she might wake up at any moment. And I was going to cut into her pink flesh. Run a knife right down her torso and then open her. Surgeons, of course, do just that, but for surgeons there’s a good reason, at least in theory: they are trying to save a life or improve its quality. I could make no such claim. At that moment, I wondered if I didn’t have more in common with a homicidal maniac than a doctor.

My older colleagues stopped joshing and watched me closely as I carried out my external examination of the body, looking for marks and any indications of the cause of death.

I’d always wanted to do this. I’d worked hard to arrive at this point. But now, suddenly, my ambition to become Keith Simpson and specialize in forensic pathology to help solve crimes seemed a schoolboy fantasy. The woman lying motionless on the porcelain table in front of me was the reality. Whatever had possessed me? I must have been insane to want to do this.

‘OK?’ asked a voice. Humour had been replaced by concern.

I took a deep breath, steeled myself, picked up the knife and placed it at the little notch in the centre of the base of her neck between the inner ends of the collar bones. Her skin did not resist as I pushed on the blade. I pulled it through the midline. Firmly because I was trying to stop my hand from shaking. Down, down, right down the body to the pubic bone.

My second cut along the same line took me through a layer of bright yellow fat. The patient was overweight. Fat solidifies and becomes more fixed to the skin once the body has cooled down in death and it can simply be peeled away. Underneath is the muscle layer and beneath that is the ribcage of the thin person who is always there inside that round body – but hidden.

My next cut was also easy, the cut through muscle. It is hard to believe how much like the carcases hanging at the butcher’s the human body looks when stripped down to the bone, and how like a steak human muscle can appear.

Now I could fold the skin sideways and outwards from the midline, as though opening a book. Even with a breast each side, this is easy. The main problem was to make sure my knife didn’t cut through the thin skin around the neck: if her relatives paying their last respects saw this, it would look shocking to them, like a stabbing. In fact, mortuary staff are highly skilled at repairing the mistakes of junior doctors – but it would cost me a bottle of whisky, something I could ill afford.

Once the skin, fat and muscle are pulled back it is easy to cut through and then remove the front of the ribs. And when I had done this, there before me were this woman’s internal organs laid out for my inspection.

Her lungs looked purple and swollen. They were flecked with soot.

‘Hmm, looks like a smoker,’ said my older colleagues, shaking their heads in disapproval. While they hid their nicotine-stained fingers.

‘But the purple colour suggests oedema,’ added one.

‘Pulmonary oedema …’ I echoed nervously. That meant the lungs had become waterlogged with fluid. This can happen when the heart is failing from disease but I knew it very often happens during the actual process of dying as the heart finally fails. Since death can be caused for one of a thousand reasons, waterlogged lungs alone are not usually helpful for diagnostic purposes.

I opened the sac inside which the heart nestles. It is just to the left side of the chest.

‘No blood or excess fluid. But it looks like she’s had a massive infarct,’ I said quickly, before anyone could tell me. About a third of the muscle at the front of the heart was distinctly paler than the rest, indicating that it had been deprived of its blood supply and oxygen. A myocardial infarct, colloquially called a heart attack, is the death of heart muscle: if the patient survives the initial damage then eventually the muscle becomes scarred. But this heart attack was too recent for scarring.

‘What was her blood pressure the last time it was taken?’ they asked me.

‘High. 180/100.’

‘High blood pressure … oh, and she was such a big-hearted woman,’ hinted the others.

It looked like a normal heart to me.

‘Is it enlarged?’

‘Wall of the left ventricle seems a bit thick … weigh it.’

The heart weighed 510g. That’s huge.

They said, ‘What do you think?’

‘Um … lungs full of fluid. High blood pressure, left ventricle enlarged and an infarct. One of the coronary arteries is blocked by thrombus.’

‘Yes. But which one?’

Back to Anatomy class. The anatomy of the heart. For my own personal reasons, I’d spent a lot of time studying this organ. Its structure. Its pathology. Its associated pathogenic mechanisms. Its arteries. Its valves. Especially the mitral. Yes, I knew about hearts.

‘There should be a blockage in … er … the left anterior descending artery?’

They nodded. ‘Take a look!’

I did, and there it was. A big, red, solid clot that had halted blood flow along the artery, depriving the heart muscle of the blood and oxygen it needed. And so, it had simply died.

What a remarkable mechanism the human seemed to me that day. As my fear drained away I became absorbed in my work. But I still had time to experience that sense of wonder at the body: its intricate systems, its colours and, yes, its beauty. For blood is not just red – it is bright red. The gall bladder is not just green, it is the green of jungle foliage. The brain is white and grey – and that is not the grey of a November sky, it is the silver-grey of darting fish. The liver is not a dull school-uniform brown, it is the sharp red-brown of a freshly ploughed field.

When I had finished examining each organ and they had all been replaced in the body, the mortuary staff moved in to work their magic of reconstruction.

‘Well done,’ one of the senior trainees said. ‘Wasn’t so bad, was it?’

It was over and I had been slow – it was well past lunchtime – but I had done all right. I had put my feelings about older women with heart problems to one side and had recalled my training and then conducted myself in an entirely clinical way. As I washed afterwards I felt flushed with relief. I was a horse that, after racing round the track for years and years, had been nervous about facing a hurdle – and then had easily cleared it.

The post-mortem turned out not to be the hardest job that day. Meeting the deceased woman’s relatives was far more demanding. Given a choice, I would have preferred not to see them at all. But they had sensibly asked for a meeting with the pathologist to help them understand why she had died. And that pathologist was evidently me.

I was saved by my colleagues, who did all the talking. I was simply not up to the task, so unbearable did I find the relatives’ shock and grief. In fact, I felt utterly helpless in the face of their emotion. Their misery seemed to transmit itself to me, to my mind and my body, as if we were attached by invisible wires. I don’t remember if I said anything at all: if I did, I probably just kept repeating how very sorry I was for their loss. Mostly I am sure I nodded while my colleagues talked.

The meeting introduced me – or, perhaps no introduction was necessary – to the awful collision between the silent, unfeeling dead and immensity of feeling they generate in the living. I left the room with relief, making a mental note to avoid the bereaved at all costs and stick to the safe world inhabited by the dead, with its facts, its measurements, its certainties. In their universe, there was a complete absence of emotion. Not to mention its ugly sister, pain.