The Dead Truth

Forensic Pathology

I feel sorry for today’s medical student. Cue the standard old fart saying - “back-in-our-day” - we were exposed to a host of subjects and experiences that are no longer part of the medical school curriculum. Today’s students miss out on the intricacies of nutrition (which explains why some doctors recommend kale smoothies for cancer), the thrills of visiting sewage treatment plants or venereal disease clinics as part of public health, the details of myriad toxins, and the most fascinating of all - forensic pathology. This lack of knowledge does have consequences, which is why you should never call your doctor if you have questions about diet or when your child chews on an indoor plant leaf. They will just Google the question or use today's AI.

Roll the clock back to 1966, Johannesburg, South Africa.

Arriving anxious one morning at the Government Laboratories, the forensic pathologist’s secretary escorted a small group of medical students into a cavernous hall. She pointed to one of the many tables that filled the morgue, half of which were occupied by corpses. The one she indicated was presided over by a short, stocky man wearing a filthy, blood-stained plastic apron. His rubber boots were covered with brown, old, caked blood. Smoke curled from a cigar that he had laid on the edge of the concrete slab. His back was towards us. We approached gingerly and then one of us had the temerity to say, “Good morning, Sir. We are the group scheduled for today’s case.” He spun around and glared.

We had interrupted a busy day, and he was in no mood to spend any time teaching medical students. He stared icily at us and said nothing - a teaching method that, ironically, was still more effective than most modern medical education. The victim on the cold slab had succumbed to multiple stab wounds. Such injuries were widespread in South Africa, as guns were not widely available at that time, so most disputes or feuds were settled with knives or clubs, the latter under the colloquial name of knobkerrie. The pathologist picked up a huge knife from the instrument tray, of the type used to slice liver. Think 14-inch chef's knife. He turned to the corpse splayed out on the concrete slab and, in a single stroke, buried it to its hilt in the chest. He pointed at me, gesturing with his fingers to come to the table. “Now describe to your colleagues the difference between a pre-mortem and a post-mortem stab wound.”

I was speechless for a moment and then muttered a few words, which obviously did not please him. “Have you no eyes? Are you unable to make a simple observation? Can't you think? God, what sort of students are they letting in these days?” Needless to say, this was not a good start to my forensic education; however, the graduation requirements necessitated that we attend a minimum number of forensic autopsies, which were meticulously tracked through an attendance record. All of us just met the minimum requirement. Each week, we hoped that the case would be a simple, clean homicide or suicide; not a burn victim, termed “crispy critters” (a nickname that would make Colonel Sanders wince) or a drowning which produced a “purple floating bloater”. And then there was always fear of the maggots if a corpse was found many days after death. These are part of nature’s original crime scene investigators, although they destroy evidence.

Forensics has been a long-standing tradition in all British-inspired medical education. Indeed, forensic pathology is an accepted and essential academic discipline. Perhaps it was the Sherlock Holmes effect, but places like Scotland Yard always used formally trained forensic pathologists from the University of London (Guy’s Hospital) for their high-profile cases. I was later shocked to discover that such a system did not exist in the USA. The coroner system that has developed in the United States is a political and amateurish mess, apart from some excellent medical examiners in a few major cities. It dawned on me that if one wanted to dispatch someone and not be caught, the USA was the country for such a deed. We will return to this theme later — not plotting murder, but the condition of forensic pathology. We could post tourism signs such as “Welcome to America: Where your murder might be ruled 'Natural Causes' by a Funeral Director turned Coroner!”

The American coroner system represents democracy at its best. In many jurisdictions, the person responsible for determining the cause of death is elected based on their ability to shake hands and kiss babies, not their knowledge of rigor mortis or toxicology. We have coroners who are funeral directors (vertical integration), insurance salesmen, and farmers. Every jurisdiction has different requirements for training and certification. It is a hodgepodge of rules and regulations..

At this juncture in our medical training, we were far more interested in the living than the dead, and so none looked forward to the weekly trek to the government laboratories for our dose of forensics. The lectures, on the other hand, were less intimidating. Some were even interesting. The highlight of the course was the visit from Sir Keith Simpson, perhaps the most famous forensic pathologist in the world at the time. He had written the textbooks on forensic pathology and reportedly had performed more autopsies than anyone on earth. Among his more famous cases were the acid bath murders of John Haig, during which he uncovered gallstones and dentures in the fatty sludge in the bath and was able to identify one of the victims. He was even employed by the country of Siam (now Thailand) to investigate the death of its king in 1948.

His lecture was riveting. I recall one slide that showed a severed hand brought to him by Scotland Yard. It had been found in a London park. He instantly recognized that it was a prank being played by a group of medical students from one of the local universities. The clue was that a couple of muscles had been carefully dissected. Sir Simpson’s autobiography, Forty Years of Murder, became a bestseller. Even so, most of us were merely satisfied with passing the forensic examinations with a minimum of work or much investment of time. None of us had any pretensions of going into the field as a career.

Many decades later, forensics developed a certain cachet, attracting a new generation of Sherlock Holmes wannabes. The field expanded to include dental, computer, finance, genocide, toxicology, botany, archaeology, and many other areas, although traditional medical forensics languished in relative obscurity despite television programs such as CSI (Crime Scene Investigation), which overly romanticized the field. This depiction bears little resemblance to reality, a common problem among most reality shows. In part, the interest in forensic sciences was fueled by the numerous new opportunities to commit mayhem and a variety of flashy new technologies.

The CSI effect created a generation of jurors who expected DNA results in 45 minutes and assumed every forensic lab had equipment that looked like it belonged on the starship Enterprise. Meanwhile, real American forensic labs were using equipment that looked like it belonged in a 1970s community college chemistry class, operated by overworked technicians who hadn't seen a raise since the Clinton administration.

In the United States, very few pathology residents ever consider a career in forensic pathology. There are no academic training programs, and little academic recognition. A small number of fellowships are offered by excellent medical examiners, but the field is regarded as something one does if unable to secure a "real" job. Despite this systemic neglect, some superb forensic pathologists rose to prominence in the USA in medical examiner's offices such as LA County, New York, Allegheny County (PA), Dallas County (TX), Dade County (FL), King County (WA), and others. Many are credentialed in forensics by the American College of Pathology.

One indictment of American forensic pathology is that we've created a system where the dead receive less professional attention than we give to diagnosing car problems. The cause of death may be determined by a physician who has only a passing acquaintance with the departed or the coroner. No autopsy required. At least when your mechanic gets it wrong, your car doesn't end up buried six feet underground with the wrong cause of death on its death certificate.

Notwithstanding my disdain for this discipline, two decades later, I was deputized to be a medical examiner. But this tale will have to wait.