Body of Work, by Christine Montross

I was speaking with a bookish friend recently, and he mentioned Dr. Sherwin Nuland's book, How We Die, which he hadn't read.  "You must," I told him. "It's required reading for anyone who is planning to die... and no, that is not everyone.  Many people never give death a moment's thought, let alone plan for it. It's as if they think it's optional."

Pada Malam Saya Bertemu Teribuana,
original painting by Mohd Hairi Yaakub

Body of Work, Christine Montross' account of her first-semester anatomy course and its requisite dissection of a human cadaver, is a very lyrical meditation (Dr. Montross is also an award-winning poet) on our feelings about the treatment of dead bodies. Moreover, it's a remarkable look at what makes physicians different from the rest of us. I would recommend this book very strongly to anyone who is facing a lot of time in hospitals. Will it give you any better understanding of medical technology?  No, but it may give you some insight into the doctors.

This is a medical school memoir, but atypical in that the focus is on the relationship between a medical student and her cadaver. The dissection takes all of the first semester at Brown Medical School, a period of four months. Each team of four students is allotted one cadaver. The bodies are preserved in formalin, with their heads and limbs wrapped in gauze to prevent dehydration. Christine and Tripler, one of her teammates and a former ballet dancer, decide they need to see the face of the woman whose body they will dissect and so unwrap her head early in the semester. Both are stunned by how lovely she is. Or was? As she has no navel, another teammate suggests that they call her Eve. From the start, the students wrestle with emotional and intellectual dilemmas: Is this cadaver "human"? They learn things from the dissection that they can learn no other way -- looking at a picture of a skull can in no way prepare them for the difficulty in sawing through it or navigating its inner canyons -- yet the process often feels brutal. At one time or another, they all wonder, are we desecrating this corpse, and if so, can the benefit justify it?

I was amazed by the differences between the cadavers.  Organs and structures differ in size, in colour, and in some cases, in location.  Of course we all know about external physical variations, but I'd always expected that my heart or thyroid gland would look pretty much like every other woman's. Eve, despite being the smallest cadaver in the lab, had the largest stomach. Such irregularities illuminate the staggering challenges of doctoring, especially of surgery.  Montross describes an operation in which the surgeons cannot locate one of the major blood vessels to cauterise it, and the patient's abdomen fills with blood faster than anyone can suction it out. Four surgeons finally find the vessel and tie it. Moral of the story: there is no such thing as "routine" surgery, because there is no such thing as a standard body.  It struck me as ironic that the one organ which looks pretty much the same from one cadaver to another is the same one in which I would expect to see the greatest variation:  The brain. Montross wonders at this as she simultaneously tries to come to grips with her grandfather's dementia.

When I look at eighteen brains held in the hands of my classmates, I cannot differentiate one from another -- not even in the way that one heart varied from another, or muscles did, or bones. Where, then, in the crenellations of the brain's tissue is the explanation for how a man's reason can depart...?

As the semester progresses, the students dissect with more confidence. They've moved beyond their squeamishness; they are more familiar with the bodies and the dissecting tools. Their very last task, however, is to dissect the head. Some of them behold their cadavers' faces for the first time. One woman flees the lab to vomit. (She quickly ascribes her queasiness to Ramadan fasting, knowing that she, as a doctor-in-the-making, should not display weakness.) Montross herself suffers nightmares and insomnia as they begin to remove Eve's face, eyes and brain.  This last stage of dissection takes a steep toll on the students.  The head is, after all -- much more so than, say, the gall bladder -- our most "human" body part.

When I get home, I take a scalding shower. I scrub my hair, brush my teeth twice, inhale water in my nose until I choke to try to rid it of the smell of the bone dust. That night, at home, Trip calls me to check in. She says that after lab she sat in her car and cried.

Portrait 14, from the Skeleton Series
Original painting by Mohd Hairi Yaakub

The dissection process is the medical student's first confrontation with establishing an appropriate emotional distance between doctor and patient. Montross also relates medical interviews that the students conduct, first with actors, then with real patients.  The first is to see how the students cope with potentially surprising disclosures. The actors might report that they enjoy unusual sexual practices or use illegal drugs. The student doctors must learn to take it all in with equanimity. More heartbreaking are the interviews with real patients, who look hopefully and expectantly to the first-year medical students in their authority-conveying white coats. The patients are unaware that, although the students could name all blood vessels leading into the heart, they had as yet learnt nothing of disease and healing.

The line between caring and callous is not the only nebulous border with which the medical students wrestle. The layman might well assume that the distinctions between alive and dead, between male and female, are among the simplest.  Montross ponders a patient who is yellow in colour, has no sign of any brain or nervous system activity, and is kept alive by machinery which performs the barest critical functions. Is he alive, or not?  His family maintains that he is; Montross felt that his brain death was the end. Who is right?

At the opposite end of life, as she studies embryonic development, gender distinctions grow ever more fuzzy. All embryos start with identical sexual structures which differentiate during gestation.  So will it be a boy or a girl?  Or some of each?

...like all bodily pathways, there can be wrong turns, missed steps, interrupted directions. We learn that even physical gender -- one of the physiologic distinctions we take as the most basic -- is not nearly the black-or-white, male-or-female, pink-or-blue differentiation we have classified it to be... the most widely used pathology textbook in medical schools acknowledges the murkiness of this territory.

She goes on to quote the textbook, identifying four markers determining whether one is male, female, or a muddle of both. Genetic sex:  Is the Y chromosome present? Gonadal sex: What are the characteristics of the sexual glands? Ductal sex: What type of ducts connect the sexual organs? Phenotypical or genital sex: What is the appearance of the external sexual genitalia?

The lack of clear definition -- even lack of clarity regarding the criteria for definition -- surfaces and resurfaces as a theme in medicine. What is male and what female? When is a person alive, and when dead? At times, in fact at most times, specific knowledge in medicine seems to be better understood than general knowledge. 

I think that most of us who are not in the medical field view doctors as vastly knowledgeable and skilled.  Purveyors of answers. And, of course, they are, but this book reminded me of how much they do not -- and perhaps cannot -- know. Our bodies are not machines, and doctors are not mechanics. The simplest questions seem to have the most elusive answers.  Full understanding is impossible.

At the end of their dissection, Montross' team has not determined why Eve has no belly-button.

Dr. Goslow hypothesizes that she had some kind of abdominal surgery and that in the closing of the surgical wound the umbilicus got tucked in, like a seam. "But there's no scar," we protest.  He shrugs. "Maybe she had the surgery at such a young age that the scar just faded away."
We are not satisfied. There was no evidence of major surgery inside Eve's abdomen. There was no scar. And so it remains a mystery, a symbol of how some things about Eve remain unknowable, that our understanding of her cannot help but be only partial, even after the dissection is complete. 

At the end, Montross goes to the lab to bid Eve a final farewell.  (Her remains are sent off either for burial or cremation, as the family wishes.)  She tries to calculate the gift that Eve has given her, and she realises that, when her mother describes her grandfather's femoral artery bypass, she immediately visualises Eve's femoral artery.  When listening to a living patient's lungs, she recalls the look and feel of Eve's.

My hours with her neither cured her nor eased her suffering. Bit by bit, I cut apart and dismantled her, a beautiful old woman who came to me whole. The lessons her body taught me are of critical importance to my knowledge of medicine, but her selfless gesture of donation will be my lasting example of how much it is possible to give to a total stranger in the hopes of healing. That lesson, when I am called to treat critically ill patients who no longer appear human, and prisoners, and demented grandfathers who are dying and angry and scared, is the lesson I hope beyond all else to have absorbed.  

Dr. Christine Montross is now practicing and teaching psychiatry in Rhode Island, U.S.  Body of Work was Washington Post Best Nonfiction Book of the Year and New York Times Book Review Editor’s Choice.

A note on the illustrations for this blog entry:  They are a blatant and unapologetic promotion of Hairi's work. He is an enormously talented Malaysian artist, and if you'd like more information about him, please leave a comment and let me know how to contact you.