Humanism and Pathology: The Anatomy Lesson

The following essay was written by physician ethicist Steven Miles who gave me permission to post the full text here. It was originally published in Clinical Anatomy 4:456-459 (1991) and then reprinted in the APA Newsletters, Spring 1999. The essay I think presents the reader with an understanding of the humanistic significance of the pathologic examination on the deceased person as well as the ones who are still alive. Doctors are not dealing with a “lump of flesh” either in the dead or living but with a human being who while alive permits themselves to “submit to procedures which in other circumstances are assaults” and who, in death, becomes through a “family’s gift” of their loved one a source of anatomic and pathologic education but also including as Dr. Miles writes “a special honor” for those who are “just beginning to learn the profound decorum that is due those who entrust their loved ones or themselves to our gaze.”

As you see, there should be something beyond simple objectivity when physicians apply their discipline and professional skills on their human patients. ..Maurice.

The Anatomy Lesson
Steve Miles
Hennepin County Medical Center
Center for Bioethics, University of Minnesota

At first, I did not really see my cadaver’s face. It was not that I avoided the encounter; it was just that the face was so unrevealing. Preserving fluids slightly swell the tissues of the face so that wrinkles—the recorded history of expression, mood, and outlook—were stretched smooth and not so obvious to my untrained eye. Death ablates the subtle, vital expressions which we learn to read so carefully. Purple-grey paints over the clue of skin color: the tan of an outdoors man whom I would learn to approach forthrightly, the pallor of chronic illness which I would later see as an omen of wariness at yet another doctor, the blush that would call for extra attention to drapes during an examination, or the blanching at my inquiry into a mortal condition which would come to alert me that reassurance is needed and will not be heard. A face is a message that we read at a distance. If it tells us nothing, we skim by to other things.


The hands are different. We know a person’s hands by active, intimate encounter. We hold hands. We shake hands. We speak of handicraft. Thoreau and Marx both spoke of life lived by the work of hands, rather than by the rational manipulation of things or others. Action and encounter is the essence of hands; their stillness emphasized his loss.


These were middle aged hands, thick callouses showed him to be a working man. An amputated index finger suggested some danger in his work; the calloused stub showed that his manual labor did not stop simply for loss of his finger. He was a man of tools, of practical things; clinicians are practical people too. I could not help but wonder what else these hands had done in his 50 or more years: the child they had held or how they had made love. As I dissected the hands, I marveled at the intricacy of the muscles and nerves which are capable of such expressiveness but which, of themselves, express nothing.


By the time I got to the face, I could see the signs of past expression. Fillings were the work of another colleague. A tattoo said that he had been in the Navy. His teeth and his fingers were stained nicotine brown, his lungs black with carbon. The appendix was gone, fibrosis showing the handiwork of a colleague who had come here before me. His body bore no stigmata of chronic disease; death had come suddenly. Coronary artery disease was present. There were no other clues.


And how had this man come to me? Dying was not sufficient; a gifting had also occurred. Since he had died suddenly, it must have been others who knew this man of tools, who had made this gift in his memory. It has not always been so. For the larger part of the history of our profession, we learned anatomy by theft, by secret deals for stolen bodies, or from the unclaimed bodies of criminals or of persons without families who died in public places. In the 19th century, bodies began to be gifted. Learned men donated their heads for their colleagues’ urgent scrutiny; Walt Whitman’s brain was disappointingly small (Gould, 1981).


The gifting of cadavers was not simply a political reform of irregular or criminal acts. It was a social response to a remarkable event in the 19th century when we learned to see with what Foucault calls the "clinical gaze." (Foucault, 1973). Before the gaze, physical signs were just signs. Like astrology, signs were a readable phenomenon which foretold a clinical future and suggested some dismal constellation of traditional, ritual therapies. But these signs and therapies were not causally related to the morbid process. A hint of the impoverished medical view of the plague which killed a third of Europe (Gottfried, 1983), survives, as a nursery rhyme: "Ring around the rosie, pockets full of posie, ashes, ashes, we all fall down. " The dramatic invention of the clinical gaze of pathophysiology was the invention upon which modern medicine (asepsis, Koch’s postulates, and DNA probes) is based.

Ring around the rosie---Beginning with a benign appearing well-circumscribed, erythematous, carbuncle at the point of entry

Pockets full of posie---The infection quickly spreads to produce large pus-filled lymph node abscesses, leading to

Ashes---The blackish spots of embolizing infection, or perhaps

Ashes---The blue-gray pallor of peripheral cyanosis of impending shock or of the hypoxia of the pneumonic plague, until . . .

We all fall down---Death inevitably follows.1

The abscess was the focus of the most productive early research. Its wall became recognized as the remains of normal cells that had died and the start of a defensive scar that failed. New entities (Koch’s tubercles) could be seen in the debris, the abscess cavity, and within still living cells. The front of cell death spread outward, the patient unaware (without signs or symptoms) until the dying front of the abscess ruptured into a bronchus producing purulent sputum or a pulmonary artery with catastrophic hemoptysis. A hidden sequence of cause-effect, cause-effect, cause-effect preceded signs and symptoms, made them interpretable, and pointed to intervention.


Pathophysiology is the foundation of our claim to efficacy but it demanded a steep price of society and patients. To receive its benefits, patients had to surrender their own sense of the meaning of illness, and suffering and wellness to our radically abstract interpretation of their need and experience. In recognition of the value of this new invention, society made a gift of what we had previous stolen or picked up as refuse. Because pathophysiology demands such a surrender, our abstract clinical objectivity is the foundation of our efficacy but not of our honor. Our honor rests on the trust that we will hold our profound clinical objectivity accountable to the fundamental conviction that patients are persons (Kass, 1985). We may only pretend that our patients are objects or mechanisms.


Clinical objectivity is not truth. It is a temporary expedient, a tool, in service of the patients’ humanity. Our patient’s trust that we do not really believe that they are objects leads them to submit to procedures which in other circumstances are assaults (with knives), and poisonings(with carbolic acid or curare), and sexual crimes, and to questions which are beyond the most intimate family conversation. Patients become angry and frightened and even leave medical care when we forget ourselves and take our tools to be the essence of our compassion.


A family’s gift of the bodies of those it loves to the relentless objectivity of the anatomy laboratory is the highest mark of their respect. It is special honor that this gift is made to those who are just beginning to learn the profound decorum that is due those who entrust their loved ones or themselves to our gaze.


Over the months, we dissected my cadaver until little remained but sliced flesh on bones. It was hard to take his hand in mine and dissect it. I dreamt of his hands. He departed as he came: nameless in a plastic bag dropped into a gurney. It bothers me that I could not say, until now, how grateful I am.


My speculations about my cadaver’s life are only speculations. Their factualness is of no consequence. It was my way to cope with the shock of the anatomy laboratory (Penny, 1985). But, within limits, this personification of my cadaver is healthier and truer than coping with human dissection by pretending that a cadaver is merely a lump of flesh (Bertman and Marks, 1989). Pretending the cadaver is just flesh is not true. Such a pretence will not ease your disquiet and if it does, you, your patients, and our profession will be the worse for it.


The anatomy laboratory recapitulates both the history and the present moment of medicine. A person voluntarily disrobes and is objectified; insight is gained and put to the pursuit of wholeness. Thus, properly viewed, the anatomy laboratory is a clinical encounter—a doctor and a willing human being.

References

Bertman, S.L., and S.C. Marks. 1989. The dissection experience as a laboratory for self discovery about death and dying. Clin. Anat. 2:103-113.
Foucault, M. 1973. The Birth of the Clinic: An Archeology of Medical Perception. New York: Vintage Books.
Gottfied, R.S. 1983. The Black Death: Natural and Human Disaster in Medieval Europe. New York: Free Press, p. xiii.
Gould. S.J. 1981. The Mismeasure of Man. New York: W.W. Norton, p. 92.
Kass, L.R. 1985. "Thinking about the Body." In Toward a More Natural Science: Biology and Human Affairs. New York: Free Press, p. 276-298.
Penny, J.C. 1985. "Reactions to human dissection." J. Med. Ed., 60:58-60.

Endnotes

1. Like most folk literature, the origins, original working, and even meaning of this rhyme is debated. Most scholars unhappily agree that it is about the plague. "Pockers full of posie" may, however, have referred to sachers of clove and other spices that were worn over the nose to prevent infection. "Ashes, ashes" may have originally been something like "Ah-shoo, ah-shoo" or "Ti-shoo, ti-shoo" evoking the sneeze from pneumonic plague. A minority of scholars with more pleasant thoughts suggest the rhyme is a courting dance and that "all fall down" is a curtsy.