Complications (25 page)

What you can’t be nowadays is mealymouthed about it. I once took care of a woman in her eighties who had given up her driver’s license only to get hit by a car—driven by someone even older—while she was walking to a bus stop. She sustained a depressed skull fracture and cerebral bleeding, and, despite surgery, she died a few days later. So, on the spring afternoon after the patient took her last breath, I stood beside her and bowed my head with the tearful family. Then, as delicately as I could—not even using the awful word—I said, “If it’s all right, we’d like to do an examination to confirm the cause of death.”

“An
autopsy?
” a nephew said, horrified. He looked at me as if I were a buzzard circling his aunt’s body. “Hasn’t she been through enough?”

The autopsy is in a precarious state these days. A generation ago, it was routine; now it has become a rarity. Human beings have never quite become comfortable with the idea of having their bodies cut open after they die. Even for a surgeon, the sense of violation is inescapable.

Not long ago, I went to observe the dissection of a thirty-eight-year-old woman I had taken care of who had died after a long struggle with heart disease. The dissecting room was in the sub-basement, past the laundry and a loading dock, behind an unmarked metal door. It had high ceilings, peeling paint, and a brown tiled floor that sloped down to a central drain. There was a Bunsen burner on a countertop, and an old-style grocer’s hanging scale, with a big clock-face red-arrow gauge and a pan underneath, for weighing organs. On shelves all around the room there were gray portions of brain, bowel, and other organs soaking in formalin in Tupperware-like containers. The facility seemed run-down, chintzy, low-tech. On a rickety gurney in the corner was my patient, sprawled out, completely naked. The autopsy team was just beginning its work.

Surgical procedures can be grisly, but dissections are somehow worse. In even the most gruesome operations—skin grafting, amputations—surgeons maintain some tenderness and aestheticism toward their work. We know that the bodies we cut still pulse with life, and that these are people who will wake again. But in the dissecting room, where the person is gone and only the shell remains, you naturally find little delicacy, and the difference is visible in the smallest details. There is, for example, the simple matter of how a body is moved from gurney to table. In the operating room, we follow a careful, elaborate procedure for the unconscious patient, involving a canvas-sleeved rolling board and several gentle movements. We don’t want so much as a bruise. Down here, by contrast, someone grabbed my patient’s arm, another person a leg, and they just yanked. When her skin stuck to the stainless-steel dissecting table, they had
to wet her and the table down with a hose before they could pull her the rest of the way.

The young pathologist for the case stood on the sidelines and let a pathology assistant take the knife. Like many of her colleagues, the pathologist had not been drawn to her field by autopsies but by the high-tech detective work that she got to do on tissue from living patients. She was happy to leave the dissection to the assistant, who had more experience at it anyway.

The assistant was a tall, slender woman of around thirty with straight sandy-brown hair. She was wearing the full protective garb of mask, face shield, gloves, and blue plastic gown. Once the body was on the table, she placed a six-inch metal block under the back, between the shoulder blades, so that the head fell back and the chest arched up. Then she took a scalpel in her hand, a big No. 6 blade, and made a huge Y-shaped incision that came down diagonally from each shoulder, curving slightly around each breast before reaching the midline, and then continued down the abdomen to the pubis.

Surgeons get used to the opening of bodies. It is easy to detach yourself from the person on the table and become absorbed by the details of method and anatomy. Nevertheless, I couldn’t help wincing as she did her work: she was holding the scalpel like a pen, which forced her to cut slowly and jaggedly with the tip of the blade. Surgeons are taught to stand straight and parallel to their incision, hold the knife between the thumb and four fingers, like a violin bow, and draw the belly of the blade through the skin in a single, smooth slice to the exact depth desired. The assistant was practically sawing her way through my patient.

From there, the evisceration was swift. The assistant flayed back the skin flaps. With an electric saw, she cut through the exposed ribs along both sides. Then she lifted the rib cage as if it were the hood of a car, opened the abdomen, and removed all the major organs—including the heart, the lungs, the liver, the bowels, and the kidneys. Then the skull was sawed open, and the brain, too, was
removed. Meanwhile, the pathologist was at a back table, weighing and examining everything, and preparing samples for microscopy and thorough testing.

For all this, however, I had to admit: the patient came out looking remarkably undisturbed. The assistant had followed the usual procedure and kept the skull incision behind the woman’s ears, where it was completely hidden by her hair. She had also taken care to close the chest and abdomen neatly, sewing the incision tight with weaved seven-cord thread. My patient seemed much the same as before, except now a little collapsed in the middle. (The standard consent allows the hospital to keep the organs for testing and research. This common and long-established practice has caused huge controversy in Britain—the media have branded it “organ stripping”—but in America it remains generally accepted.) Most families, in fact, still have open-casket funerals after autopsies. Morticians employ fillers to restore a corpse’s shape, and when they’re done you cannot tell that an autopsy has been performed.

Still, when it is time to ask for a family’s permission to do such a thing, the images weigh on everyone’s mind—not least the doctor’s. You strive to achieve a cool, dispassionate attitude toward these matters. But doubts nevertheless creep in.

One of the first patients for whom I was expected to request an autopsy was a seventy-five-year-old retired New England doctor who died one winter night while I was with him. Herodotus Sykes (not his real name, but not unlike it, either) had been rushed to the hospital with an infected, rupturing abdominal aortic aneurysm and taken to emergency surgery. He survived it, and recovered steadily until, eighteen days later, his blood pressure dropped alarmingly and blood began to pour from a drainage tube in his abdomen. “The aortic stump must have blown out,” his surgeon said. Residual infection must have weakened the suture line where the infected aorta had been removed. We could have operated again, but the patient’s chances were poor, and his surgeon didn’t think he would be willing to take any more.

He was right. No more surgery, Sykes told me. He’d been through enough. We called Mrs. Sykes, who was staying with a friend about two hours away, and she set out for the hospital.

It was about midnight. I sat with him as he lay silent and bleeding, his arms slack at his sides, his eyes without fear. I imagined his wife out on the Mass Pike, frantic, helpless, with six lanes, virtually empty at that hour, stretching far ahead.

Sykes held on, and at 2:15
A.M.
his wife arrived. She turned ashen at the sight of him, but she steadied herself. She gently took his hand in hers. She squeezed, and he squeezed back. I left them to themselves.

At 2:45, the nurse called me in. I listened with my stethoscope, then turned to Mrs. Sykes and told her that he was gone. She had her husband’s Yankee reserve, but she broke into quiet tears, weeping into her hands, and seemed suddenly frail and small. A friend who had come with her soon appeared, took her by the arm, and led her out of the room.

We are instructed to request an autopsy on everyone as a means of confirming the cause of death and catching our mistakes. And this was the moment I was supposed to ask—with the wife despondent and reeling with shock. But surely, I began to think, here was a case in which an autopsy would be pointless. We knew what had happened—a persistent infection, a rupture. We were sure of it. What would cutting the man apart accomplish?

And so I let Mrs. Sykes go. I could have caught her as she walked through the ICU’s double doors. Or even called her on the phone later. But I never did.

Such reasoning, it appears, has become commonplace in medicine. Doctors are seeking so few autopsies that in recent years the
Journal of the American Medical Association
has twice felt the need to declare “war on the nonautopsy.” According to the most recent statistics available, autopsies have been done in fewer than 10 percent of deaths; many hospitals do none. This is a dramatic turnabout.
Through much of the twentieth century, doctors diligently obtained autopsies in the majority of all deaths—and it had taken centuries to reach this point. As Kenneth Iserson recounts in his fascinating almanac,
Death to Dust
, physicians have performed autopsies for more than two thousand years. But for most of history they were rarely performed. If religions permitted them at all—Islam, Shinto, orthodox Judaism, and the Greek Orthodox Church still frown on them—it was generally only for legal purposes. The Roman physician Antistius performed one of the earliest forensic examinations on record, in 44 B.C., on Julius Caesar, documenting twenty-three wounds, including a final, fatal stab to the chest. In 1410, the Catholic Church itself ordered an autopsy—on Pope Alexander V, to determine whether his successor had poisoned him. No evidence of this was apparently found.

The first documented postmortem examination in the New World was actually done for religious reasons, though. It was performed on July 19, 1533, on the island of Espanola (now the Dominican Republic), upon conjoined female twins connected at the lower chest, to determine if they had one soul or two. The twins had been born alive, and a priest had baptized them as two separate souls. A disagreement subsequently ensued about whether he was right to have done so, and when the “double monster” died at eight days of age an autopsy was ordered to settle the issue. A surgeon, one Johan Camacho, found two virtually complete sets of internal organs, and it was decided that two souls had lived and died.

Even in the nineteenth century, however, long after church strictures had loosened, people in the West seldom allowed doctors to autopsy their family members for medical purposes. As a result, the practice was largely clandestine. Some doctors went ahead and autopsied hospital patients immediately after death, before relatives could turn up to object. Others waited until burial and then robbed the graves, either personally or through accomplices, an activity that continued into the twentieth century. To deter such autopsies, some families would post nighttime guards at the grave site—hence the
term “graveyard shift.” Others placed heavy stones on the coffins. In 1878, one company in Columbus, Ohio, even sold “torpedo coffins,” equipped with pipe bombs rigged to blow up if they were tampered with. Yet doctors remained undeterred. Ambrose Bierce’s
The Devil’s Dictionary
, published in 1906, defined “grave” as “a place in which the dead are laid to await the coming of the medical student.”

By the turn of the twentieth century, however, prominent physicians such as Rudolf Virchow in Berlin, Karl Rokitansky in Vienna, and William Osler in Baltimore began to win popular support for the practice of autopsy. They defended it as a tool of discovery, one that had already been used to identify the cause of tuberculosis, reveal how to treat appendicitis, and establish the existence of Alzheimer’s disease. They also showed that autopsies prevented errors—that without them doctors could not know when their diagnoses were incorrect. Moreover, most deaths were a mystery then, and perhaps what clinched the argument was the notion that autopsies could provide families with answers—give the story of a loved one’s life a comprehensible ending. Once doctors had insured a dignified and respectful dissection at the hospital, public opinion turned. With time, doctors who did
not
obtain autopsies were viewed with suspicion. By the end of the Second World War, the autopsy was firmly established as a routine part of death in Europe and North America.

So what accounts for its decline? In truth, it’s not because families refuse—to judge from recent studies, they still grant that permission up to 80 percent of the time. Instead, doctors, once so eager to perform autopsies that they stole bodies, have simply stopped asking. Some people ascribe this to shady motives. It has been said that hospitals are trying to save money by avoiding autopsies, since insurers don’t pay for them, or that doctors avoid them in order to cover up evidence of malpractice. And yet autopsies lost money and uncovered malpractice when they were popular, too.

Instead, I suspect, what discourages autopsies is medicine’s twenty-first-century, tall-in-the-saddle confidence. When I failed to ask Mrs. Sykes whether we could autopsy her husband, it was not
because of the expense, or because I feared that the autopsy would uncover an error. It was the opposite: I didn’t see much likelihood that an error would be found. Today, we have MRI scans, ultrasound, nuclear medicine, molecular testing, and much more. When somebody dies, we already know why. We don’t need an autopsy to find out.

Or so I thought. Then I had a patient who changed my mind.

He was in his sixties, whiskered and cheerful, a former engineer who had found success in retirement as an artist. I will call him Mr. Jolly, because that’s what he was. He was also what we call a vasculopath—he did not seem to have an undiseased artery in him. Whether because of his diet or his genes or the fact that he used to smoke, he had had, in the previous decade, one heart attack, two abdominal aortic aneurysm repairs, four bypass operations to keep blood flowing past blockages in his leg arteries, and several balloon procedures to keep hardened arteries open. Still, I never knew him to take a dark view of his lot. “Well, you can’t get miserable about it,” he’d say. He had wonderful children. He had beautiful grandchildren. “But, aargh, the wife,” he’d go on. She would be sitting right there at the bedside and would roll her eyes, and he’d break into a grin.