Autopsy

One summer at college I took an EMT class. I didn't want to be an emergency medical technician; I just wanted the experience, and the nine credits of night and Saturday school, which I thought would be a cakewalk for an Army medic. (As it turned out, I did have to study, and I was hopeless at administering oxygen.)

Anyway, we were required to arrange half a day either observing autopsies or hanging around an ER. I chose the morgue because it was so much less popular.

It must have been around nine in the morning when the coroner started working on her first body. He was a 13-year-old boy who'd been riding a three-wheeler up in the mountains the day before, and it had turned over on him and he died. I couldn't see anything wrong with him that should have killed him, though. He was very pale, and his freckles were just little spots that were slightly less pale. He had curly red hair. His eyes were closed.

The coroner examined his limbs and the outside of his body, and spoke her observations into a hanging microphone as she worked. A few bruises and scrapes were all the damage he had. Then she examined the brain. She cut the skin in back of the scalp and peeled the face down from the skull like a rubber mask. I was surprised to see the back of someone's face. I'd always thought of my face as "me," not something that could be removed and replaced so neatly. The coroner sawed away the bare skull to reveal the boy's pale yellowish brain. There were little pools of inky blood, but no massive hemorrhage. Nothing conclusive.

Next she opened the rib cage to look for internal damage. She sawed big saloon door cuts through the sternum and chest. With the skin peeled back, the ribs were indistinguishable from racks of pork ribs you could buy at the supermarket. A boy that age is just the right size, and the fluorescent light on the day-old muscle makes it look exactly like pork ribs. I would dare any layman to tell them apart.

There weren't any gory injuries in the chest or belly, either, and the spine was intact. The coroner concluded the boy had died of spontaneous asphyxiation -- the three-wheeler's weight had forced oxygen out of his lungs really suddenly, and ... he was just dead. For some reason, just getting the weight off his chest hadn't sent him back over to our side of the line. "A pity. A lovely boy," the coroner said, and she put his rubbery face back over his skull so he would look good in his casket. Later, I found the boy's obituary and cut it out. I liked his picture. His eyes were open in the picture, of course, and I had never looked into them before.

Often, on meeting someone new and telling them that I'm a medical student, a question will eventually arise on the topic of dissection. "Was it weird, cutting up a dead body?"; "Could you picture them alive when you're looking at them?"; "Didn't you find it really creepy?"

Unfortunately, I can't answer these questions. A combination of the progression in teaching methodology and a shortage of those willing to donate their body to medical science means that prosection (where a qualified anatomist correctly pre-dissects the section for you) is overtaking dissection (where a bunch of idiots spend a large amount of time flicking through an anatomy book to find out exactly what that red wobbly thing was that just popped out of the abdominal cavity) as the teaching method of choice. On the upside, I didn't spend the first two years of my degree smelling of formaldehyde. On the downside, I currently know next to no anatomy.

Anatomy can be learnt later. Formaldehyde lingers.

However, I was always aware that my lack of morbid experience-telling disappointed some people. They wanted to hear how my designated body looked exactly like my old next-door neighbour. They wanted to hear tales of how we nicked body parts to play pranks on unsuspecting members of the public. They wanted to hear how half the class fainted in their first dissection session.

The problem with most Western cultures now is that we have had the experience of death - other people's death - taken away from us. Grandma no longer dies at home surrounded by her family; she's sent to a nursing home to live out the last of her days, her eventual demise being reported to her family half an hour later on the phone. Grandpa no longer has a quick death after a bout of pneumonia; he's sent to the hospital and put through all manner of 'life-saving' procedures to keep him going, before eventually contracting an antibiotic-resistant microorganism that eventually does for him. Those are of course the natural deaths. However, even unnatural deaths are the rarity rather than the norm, as they were centuries before. Health and Safety legislation means that employers are contractually obliged to prevent employees dying in any manner of stupid and painful ways. Emergency services are able to attend the scenes of accidents within minutes, adopting a 'scoop and run' approach that means that you're unlikely to see the human causalities of any motorway pile-up that you rubberneck past.

This, of course, leads to there being a great curiosity about death in those who have never seen it. This is why people such as Professor Gunther Von Hagens are able to make a fortune by showing us the dead in a popular medium. The tickets for public autopsies sell out in days. Channel four recently screened an autopsy as a series of four episodes that had viewing figure of 1.2 million. We are now so far removed from death that we actively seek it out. Metaphorically speaking of course.

So, when people expect a gruesome story from me about my experiences, I tell them about my first autopsy. Again, contrary to popular lore, it's not that easy anymore for medical students to attend autopsies. However, I was lucky enough to be sent to a small hospital as a junior medical student that actively encouraged us to attend post-mortems. I didn't know it at the time, but there was only one scheduled for the first day that I attended the morgue. I walked into the raised viewing area and cast my eye around the building. As expected, there were the shiny steel autopsy tables, the clean white linoleum, the morgue attendants wandering around with vulcanised rubber aprons. What I didn't expect was for there to be a full-sized wax model lying on one of the tables. I thought maybe they realised that this was our first time and wanted to do some teaching. Then I realised that it was a body. The body, in fact.

To this day, I still couldn't tell you why I thought the body was a wax model. Maybe it was that the abdominal fat seemed a little too yellow. Or that the inside of the rib cage was a little too well defined. The fact that the scalp had been pulled down over the face only served to confuse me more. It didn't look like a body. It looked like a man-made replica of a body. This moment of realisation only occurred after the pathologist had walked up to the examination table with a tray full of internal organs.

I've never been squeamish, but as he started slicing into the retroperitoneal fat that contains the kidneys, my stomach turned itself up and around. That was the moment I swore never to eat meat again. By the time we'd worked our way round to the liver, I thought that may I might be able to cope with eating meat again, just as long as I didn't think about it too much. By the time we'd finished the autopsy, I was ravenous, and would have pushed down and run over my own grandmother to get to the canteen to buy myself a fry-up.

That, is of course, the sort of story one wants to hear about medical students and their ghoulish ways. However, I usually continue the story with what I actually learnt and took away from the experience.

The deceased was a 55 year old gentleman who wasn't a resident in the area. He'd travelled down a couple of days beforehand to help his daughter decorate her new flat. They'd spent the morning painting, and then retired for lunch at a near-by pub. Whilst in the pub, he collapsed. Paramedics were unable to resuscitate him at the scene. His time of death was declared in the A&E department in the early afternoon. He was a slightly over-weight smoker who enjoyed his drink, and worked full-time as a builder. He'd complained of no symptoms before he collapsed, and had no significant previous medical history. Thus, a post-mortem was requested to establish the cause of death.

His cause of death was determined to be a complete occlusion of the anterior interventricular branch of the left coronary artery, secondary to an unusual, but by no means rare, congenital malformation of the vasculature of the heart. A heart attack in other words.

Walking home from the hospital that afternoon, I decided to phone my father. The suddenness of the man's death had been preying on my mind all day. He was there. Then he wasn't. He'd travelled 80 miles to see his daughter's new flat, and with no warning, he was dead. His family never saw it coming. He never saw it coming. I've been worried about my Dad's health for a while now; he's overweight and tends not to look after himself. He doesn't cut the fat off his meat and enjoys drinking. Exercise is not actively pursued, and his father, my grandfather, died suddenly from a heart attack while he was mowing the lawn one morning. Every time I thought about the body lying on the autopsy table, I saw my father's face.

Of course, my father laughed off my worries. This upset me greatly. I tried to get across to him how much I loved him, how much I needed to know that he was going to be around in twenty years time. How I worry about him, how I want him to look after himself. He still laughed, and told me not to over-react. And still, my mind played through the image of a relatively young and apparently healthy man lying on an autopsy table. The conversation ended only as it could, with me in tears and angry.

The memory of my first autopsy will never leave me. I have seen many since, and some stick in the mind more than others... but the first I will carry with me wherever I go. I think of him whenever I see a middle-aged patient who won't take his heart medication because it causes impotence. I see him everytime I'm in a restaurant and I watch a father sitting with his family, eating his way through a plate's worth of cholesterol. I see him whenever I attend to a patient complaining of a little indigestion, "but I thought I ought to get it checked out, just in case."

I see his face every time I look at my father and realise how much I love him.

My first autopsy taught me to see that life sometimes pulls up short. I'd always known this in an unrealised kind of way, but now I know it. My first autopsy taught me to try to enjoy every moment of my life that I possibly could, because that pub lunch could suddenly be my last. It also taught me to try to enjoy every moment of my loved one's lives, because they could be taken from me tomorrow.

And I'd always regret it if they died and I didn't spend those last seconds appreciating how much they meant to me.

The term autopsy derives from a classical Greek word that means `seeing for oneself'. It refers to an external and internal medical examination that is performed on a dead body by a medical examiner, pathologist, or other trained person for the purpose of determining or confirming cause of death.

The post mortem examination can be ordered by the government (i.e., the Coroner) when there is concern for criminal activities or public health. Autopsy may also be requested by the attending physician or by a family member. Privately ordered autopsies may cost between $1500.00 and $3,000.00 or more in the US.

Generally, an autopsy will include gross examination and microscopic examination, and may also include laboratory work on body tissues or fluids. Gross examination is done with the unaided eye, with observations recorded by microphone or by writing. Microscopic examination is done afterwards on prepared slides of tissue sections prepared from samples collected during the autopsy. Laboratory tests may be ordered to find evidence of disease or drugs.

Procedure

First, the exterior of the body is examined for abnormalities and findings are noted by voice, on charts or by written description.

The internal examination usually includes the vital organs: the brain and the organs of the neck, thorax and abdomen.

To remove the brain, a deep incision is made down to bone with a scalpel from the bony bump behind one ear, across the crown, and down to the same place behind the other ear. The top flap of the scalp is pulled forward and down over the face and the bottom flap is pulled down to the neck, exposing most of the skull. A bone saw is then used to cut through the skull in two intersecting arcs. That is done so the cut off part won't slide around when it is later replaced. The brain is severed from the spinal cord, which is pretty much all that holds it in. It is then carefully lifted out and placed in a jar of formalin solution, suspended by a string. The brain is very soft, and so must be `cured' for a week or more in formalin before it can be manipulated.

Next, the internal organs and glands from the neck down to the pelvis are removed. There are a number of techniques for doing that, ranging from removing them item by item to cutting out the whole kit in one piece from top, above the larynx to the bottom, at the pelvis. (This is called the Rokitansky method.) It all begins with the `Y' incision, which is made with a large scalpel. First a' V' cut is made from each shoulder down to the bottom of the sternum. This cut detours below the breasts if the subject is female. The chest flap is cut away from bone and underlying tissues and then pulled up over the subject's head. A straight cut is made downwards from the sternum to the pubis, cutting through the abdominal wall but avoiding the belly button, and then the side flaps are laid back. Then, the ribs are detached from the sternum with a bone cutter (a large frightening thing with curved blade that you may have seen in a movie or two) or bone saw. (The bone saw, by the way, is not at all intimidating. Its serrated cutting edge vibrates rather than rotates, so it cuts bones nicely but does not damage soft tissues.) The sternum is lifted out, and the ribs are pulled back, exposing the lungs and pericardial sac.

The organs are moved to a dissection table, which is often above the legs of the body. There, the organs are sliced open to reveal the internal structure, and are examined for abnormalities or disease. The esophagus, stomach and major blood vessels and ducts are also cut open and examined. Samples are taken and placed in formalin. The last and least pleasant job is `running the gut'. The intestines are taken to a sink with lots of running water and cut open for internal examination. This job may fall to a lower ranking assistant.

After curing, the brain is also sliced and examined.

After examination, the brain is usually incinerated. The remnants of other dissected organs are either sloshed back into the body cavity or incinerated. The skull and sternum are returned to their original positions and the incisions are sewn up with coarse thread, usually with the same kind of stitch used on baseballs.

As with many old crafts, there is a separation between the older purists and the impatient youngsters. The purist works with scalpels and a large, long knife, known as the `bread knife', which takes skill and produces elegant, clean cuts. Many younger prosectors prefer scissors where expedient.

The decision on cause of death is the job of the pathologist. If the pathologist was not the prosector, which is what the person who does the autopsy is called, then the judgment is made on the basis of the prosector's notes, photographs, direct microscopic examination, and lab results. The final result is a report signed by the pathologist.

http://www.neosoft.com/~uthman/Autop.html
http://www.pathguy.com/autopsy.htm

If you want to try your hand at a pathologist's job of determining cause of death, try
"Virtual Autopsy" at http://www.le.ac.uk/pathology/teach/va/titlpag1.html

Au"top*sy (?), n. [Gr. , fr. seen by one's self; self + seen: cf. F. autopsie. See Optic, a.]

1.

Personal observation or examination; seeing with one's own eyes; ocular view.

By autopsy and experiment. Cudworth.

2. Med.

Dissection of a dead body, for the purpose of ascertaining the cause, seat, or nature of a disease; a post-mortem examination.

© Webster 1913.