What the body teaches: lessons from the autopsy table.

Someone once asked me what unique understanding I as a pathologist derive from my professional contact with the dead. I said that the autopsy teaches the transience and the fragility of human life. My interlocutor replied that, in that case, the autopsy teaches nothing, "since we knew that already." He missed the point. The truth is that most human beings feel themselves indestructible. They may know that death exists and is inevitable, but this, they seem to think, applies only to others. In the inertia and unbroken continuity of their daily lives, they come to believe that a tomorrow is guaranteed for them. It takes a sudden jolt, a tragedy, a near-death experience, or a grievous, wrenching bereavement, to give an inkling--and this may be fleeting, soon forgotten--that no guarantee exists for any of us. But the spectacle of an autopsy, at least when it is watched for the first time, flashes this realization abruptly to our face. Not a purely intellectual realization, not abstract knowledge, but a "visceral" knowledge, so to speak, a cognition deeply anchored in the gut and in the marrow of our bones.

My years performing autopsies convinced me that the proximate mechanism of death--the personal style, so to speak, of "crossing" through--is highly varied and individual. Our mind is fond of classifying, and reducing the infinite variety of the world to a few comprehensible categories. Yet classifying is by no means a portrayal of reality: it is a simplifying device that we use for the sake of maintaining our sanity. When it comes to the body's breakdown, the truth is that, as a wise axiom put it, "there are no diseases, only sick patients." No two deaths are identical, even though we affix, for convenience, the same label to both. Arteriosclerosis, lupus erythematosus, and pneumonia are fine-sounding terms of Greek lineage, but they may describe organic catastrophe in some, and mere subsidiary complication in others. And the same catastrophic disease never leaves exactly the same marks of its pathology in two different patients.

Nor does it take massive destruction or the organic cataclysm of advanced, systemic diseases, to fell us. The sword of Damocles that hangs over our heads is suspended by a thin and flimsy thread, indeed. It may fall at any time. A rupture in a small blood vessel, a blood clot that is accidentally dislodged; nay, a raisin, an olive, or a cherry stuck in the larynx: it does not take much to sever the thread of our existence.

All creatures are like prisoners on death row, whose lives are prolonged thanks to indefinite postponements of their sentence. Still, man is the only prisoner who knows he is condemned to capital punishment; that the sentence is without appeal; and that it has been passed already. This was somberly depicted by Pascal, when he wrote: "Imagine a group of men condemned to death, all in chains, and of which a few are daily slaughtered in full view of the rest. Those who remain see their own condition reflected in that of their fellows, and look at each other with pain and hopelessness, anticipating that their turn is coming. This is the image of the human condition."

That man is the only being capable of understanding his future death, and worrying about it, has become commonplace in philosophy, but it requires modification on at least two counts. First, it is not at all certain that animals (those that we call "superior" animal forms, anyway), are entirely without knowledge of their future end. When we observe the lengths they go to when confronting lethal threats, we have reason to doubt the assertion that some animals don't know what death is. Needless to say, when we claim that they may "know" something about death, we are not implying that they know it in the same way as human beings know about their own death. We must admit that there are different ways of knowing; and the modus cognoscendi of animals is barred to us. These are facts we must live with: that there are different modalities of cognition, and that only some are open to us.

Second, the assertion that the human being lives anguished by the understanding of his own death, is also subject to qualification. True, it is a feature of the human mind to be able to represent events that will take place in the future, but death itself is not representable. Pascal's words once again: "All I know is that I must die, but what I ignore most of all is that very same death that I cannot avoid." So it is, for death is unthinkable in an absolute sense. We do not know--cannot know--what it consists of. There is nothing with which it may be compared. It falls entirely outside of the realm of human experience, and consequently outside of what is conceivable: How can we represent to ourselves, who live in space and time, what it means to be outside of time? Therefore, the mind naturally resists the exploration of this theme. However much we may wish to seize it and examine it inside and out, death is not an object of thought. Like all the absolute themes, this one may be compared to a perfectly smooth, round, uniform object that the mind attempts to grasp in vain. It always eludes our grasp. There is nothing in its utterly level, evenly terse surface that permits the mind to hold on to it; there is no crack, no fissure, no promontory to be hooked or secured.

It is not necessary to propose a positive ill as a cause of the fear of death. It suffices to consider that a single instant will transform a living, thinking, sentient, human being into ... a lump of decomposing organic matter; in a word: carrion. Of all the thresholds we have crossed, this one is the most heavily freighted with meaning; the most gripping, for it is the threshold that divides the passage from one state of being to another, and perhaps from being to annihilation. Are there really any grounds to fear death, which itself is "nothing"? Surely, it is unreasonable to be afraid of that which in itself is insubstantial but of course what is feared is not "a thing," but a happening. The transition is the supreme instant of an individual's life. This is what is feared. It should mean nothing to us, say the sages. Quite the contrary, it is all to us!

An essayist surveying the medical profession once wrote that he saw no differences in individual deaths. There was, in his view, neither honor nor blame annexed to human death: there exists no vile death or death heroic, he declared, no noble deaths, no courageous or cowardly deaths. There is only plain death: death unadorned, stark, always unqualified, and always repugnant. This is so, he concluded, because for the generality of humankind death comes as an imposition: it is a form of abjection to which all must submit with resignation, and which all must accept because they have no choice. "Death is the enemy" was the pugnacious motto that he would have bestowed on all the activities of medicine. A hateful enemy, degrading because forced upon us, ever to be combated adamantly, unflaggingly, and at all costs.

Regrettably, physicians intent on combating death at all costs are impervious to the many meanings of life's closure. They would replace the coarse or vulgar perturbation with another species of hurt, no less alienating for being of different, outwardly respectable ilk. I mean the hygienic hospital environment of immaculate sheets and shiny chrome, where the patient succumbs amidst intravenous tubing, oxygen tanks, and electronic display monitors: modern paraphernalia that surround the dying, aptly named by Baudrillard "the technological last rites." Better to die alone, were we so unfortunate as not to have our loved ones attending our grand finale, than in the unfeeling entrapment of autoclaved sheets, and in circumstances that degrade while pretending to alleviate.

Every human life, be it the meanest, has an inherent nobility that demands reverence. Whether a man's actions caused a great uproar in the world, or coursed obscure and sequestered in anonymity, when he is no more, his mortal remains exact an instinctive respect from all who contemplate them. My own familiarity with the autopsy suite allowed me to see this reaction many times. I do not know whence come this respect and this reverence. Nor do I think that anyone can supply an explanation, because it is not something rational. It is an affair of the heart, which in this matter, as in so many others, sees farther and clearer than the head.

I am led to these reflections by the remembrance of an individual death. Among the many that I encountered in my profession as a pathologist, this one stands out. Not because of any remarkable features in the medical or personal history of the deceased, with whom I had but a fleeting and superficial acquaintance, but precisely on account of its mediocrity, in the sense of absence of what is commonly regarded as noteworthy.

On my way to work, I used to walk through a shopping mall. One day, I encountered there a group of persons crowding the site where a middle-aged man of humble appearance had collapsed. The world being what it is, it would not surprise me to learn that he had not been immediately succored. Seeing a shabbily dressed man totter and fall, it is a safe wager that many thought to themselves, He is drunk. Charity is a virtue daily extolled, but, it has been said, that which no man is at bottom disposed to practice. By the time I reached the huddle of curious onlookers, the man, pale as a ghost, had partially recovered and had been helped to a sitting position. A woman was still trying to give him air, by fanning him clumsily with a magazine. A passerby, realizing that the sick fellow looked like a foreigner, addressed him in a loud voice.

By his look he was Hispanic; by his attire, a menial worker. I approached him to see if I could be of any help, but it was evident the man understood everything he heard, and could make himself understood without difficulty. He answered feebly to the questions put to him, and kept mumbling faintly a reiterative excuse: "I am sorry, I am so sorry ..." Since he was conscious, in no acute distress despite shroud-like pallor, and waiting for the ambulance that someone had called already, many of the curious, myself included, saw no reason to tarry. The crowd dispersed, I went to work, and thought no more of the incident.

I saw him again two days later, this time lying, naked and lifeless, on the autopsy table. He had not made it. Brought to the hospital where I worked, he had succumbed in a little over twenty-four hours after admission, from myocardial infarction. I had no previous acquaintance with this man, and developed none afterward. Neither did I participate in his treatment or witness his agony. Still, I could not but recall his apologetic, self-effacing stance when first brushed by the wing of the Angel of Death. What need did he have to excuse himself? Perhaps he expressed regret for disturbing us, the hale and the carefree. "I am sorry to die among you, here, in this shopping mall." "Please excuse me for obtruding my weakness and my finitude, here, into your daily lives." "I apologize for inconveniencing you with this awkwardness and impropriety of mine; it is entirely out of my control." This, I gather, is what he wanted to say.

Such a gentle attitude, sublime to the point of absurdity, still warms my heart merely to evoke it. In a world where the unscrupulous reign, and where callousness does not think twice before scoffing at the meek, the man's delicacy of sentiment could hope for nothing but contemptuous pity or arrant ridicule. Against a sky of blackness, where pride is abundant and magnanimity scarce, that little man, that mediocre personage, shines with uncommon refulgence. For a single good action suffices to restore our faith in goodness, as one genuine gold coin suffices to convince us that not all is counterfeit in the world. Under normal circumstances, I, like most people, would not have given him much thought. Recollecting his end, though, I am still deeply moved by his show of humble dignity and touching modesty, all the more gripping for seeing it used as a holy garment to wear on the journey to eternity. I am reminded of Ecclesiasticus 14:17: "All flesh waxeth old as a garment; for the covenant from the beginning is, Thou shalt die the death."

It is difficult to describe the throng of feelings elicited by his exanimate body. Pity for his difficult existence; for his need to struggle to eke out a bare subsistence. Indescribable compassion, upon thinking that he probably had left dependants in a state of destitution. Perhaps he had relatives in a foreign land, for whom he was doubly absent: absent for having left his homeland, and absent because now he had gone farther, to "the beyond"--the absence of an absence, which is the most difficult sort to bear. Gratitude, too, for this single unknown man had given proof that gentleness exists in a world of harshness, and that life in contemporary society is not to be deemed utterly hopeless. And respect, for having been the cause of stirring a whole train of reflections on the dignity of human life.

It was with trepidation, almost with the sense of committing a crime, that we violated the integrity of that corpse to perform an autopsy. Before tracing the first incision, we covered the face with a towel. This is part of the unwritten ritual observed by dissectors all over the world. Perhaps they feel compelled to drape the face of the cadaver because they sense that something of the self of the departed still clings to the body after it has perished. The self, wrote Kierkegaard, is made of infinite and finite components; and one might imagine the former leaving by stages. Or the soul, as the ancients believed, regrets to leave the marvel it inhabited, and hesitates for a while before taking flight.

Well conformed or afflicted by cruel deformities, the human body inspires an instinctive respect in those who must examine its inner disposition. The dead body deserves no less. Whether the dead was man or woman, rich or poor, privileged or indigent, exalted to lofty station, or, like the man of my remembrance, dying in a shopping mall and the bearer of a harsh lot, bent by ungrateful toil in the heat of the day; in any case, the body of the deceased compels reverence and circumspection. Whether their names shall be remembered down the ages, or doomed to dilution amidst the faceless, numberless multitude, the honor of kings is due to those who have been. No lesser homage must be paid to them by dissectors.

This, for a while only, of course. For after perishing, the flesh shall discompose, turn fetid and diffluent, and the cadaver then signifies danger and desolation for the living. The self is no more. All this we knew already, but none of us wants to hear. The autopsy has its way of reminding us of what we loathe and would fain pass over. Again, Ecclesiasticus (10:11) puts it with unexcelled starkness: "For when a man is dead he shall inherit creeping things, beasts and worms."

Does all this sound depressing? Indeed, but only because of our immoderate love of self. Discard, if only for an instant, all attachment to the fragile, perishable, individual "ego," and sadness vanishes. For not gloomy or lugubrious, but a happy and serene fate it will seem, to surrender to the awesome postmortem transfiguration over which nature presides. The deliquescent flesh becomes the sap of plants, and climbs toward the sun; forms new matter in the myriad, swarming creatures that are like the world's diffuse, subterranean palpitation; ascends in the soft vapors of clouds; and is at last diluted in the glimmer of the stars. There is no terror in becoming one with fecund new life, fruit, or flower. There is no shudder in what Eca de Queiros named "the sacred promiscuity of the earth" (for the latter accepts all). In his words: "she chooses not; all is good for her; the rosebush roots graze on the rot of tyrants, and of the men who once killed, bloodied, and destroyed, she makes austere oak trees and reverent cedars."

F. Gonzalez-Crussi, M.D., a writer and emeritus professor of pathology, lives in Chicago. His latest book, On Being Born and Other Difficulties, will be published this summer by Overlook Press. This article and the two that follow by Michael Baxter and Richard Alleva complete a two-part series on "Thinking about Death" that began with the January 30, 2004 issue.