剖还是不剖?

By Atul Gawande

The first documented postmortem examination（验尸）in the New World was actually done for religious reasons， though. It was performed on July 19， 1533， on the island of Espa？ola [now the Dominican Republic（多米尼加共和国）]， upon conjoined（连体的）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（洗礼）them as two separate souls. A disagreement subsequently ensued（接着发生）about whether he was right to have done so， and when the “double monster” died at eight days of age an autopsy（验尸，解剖）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（苛评，责难）had loosened， people in the West seldom allowed to autopsy their family members for medical purposes. As a result， the practice was largely clandestine（秘密的，暗中的）. 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（同谋犯）， an activity that continued into the twentieth century. To deter（阻止）such autopsies， some families would post nighttime guards at the grave site—hence the term“graveyard shift（夜班）.” Others placed heavy stone on the coffins. In 1878， one company in Columbus， Ohio even sold “torpedo（爆炸装置）coffins” equipped with pipe bombs（土制管式炸弹）rigged（装备）to blow up if they were tampered with（胡乱摆弄）. Yet doctors remained undeterred（未被吓住的）. Ambrose Bierces The Devils 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 Rudof Virshow 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（肺结核）， reveal how to treat appendicitis（阑尾炎）， and establish the existence of Alzheimers disease1（阿尔茨海默病）. 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（緊抓）the argument was the notion that autopsies could provide families with answers—give the story of a loved ones life a comprehensible ending. Once doctors had insured a dignified and respectful dissection（解剖）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， its 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（归因于）this to shady（阴暗的）motives. It has been said that hospitals are trying to save money by avoiding autopsies， since insurers dont pay for them， or that doctors avoid them in order to cover up evidence of malpractice（治疗不当）. And yet autopsies lost money and uncovered malpractice when they were popular， too.

《医生的修炼：在不完美中探索行医的真相》（Complications： A Surgeons Notes on an Imperfect Science）是一本真实的医生手记，记录了作者葛文德从见习生到一名成熟老练的外科大夫的经历。书里对外科手术精准入微、触目惊心的描写读起来令人有些毛骨悚然，然而这些描写也是本书的精华。作者的笔犹如犀利的手术刀，在触及病人痛处的同时也触动了读者的内心，引起读者对医生行业伦理的深度思考。《时代周刊》评论葛文德“有一支犀利如手术刀的笔，一双如X光般具有穿透力的眼睛”，而他描述的每一个病例故事，“从枪伤到病态肥胖到噬肉菌，都是迷你惊悚小说……这是一本让人目不转睛、不忍释卷的精彩之作。”本期节选了书的开头部分，作者描述了过去医生们对验尸的热衷和民众对验尸的看法。一开始作者认为有了现代医学设备和技术后，验尸的实用性已经大大下降，然而一次意外的治疗经历改变了他这个看法。

Instead， I suspect， what discourages autopsies is medicines twenty-first-century， tall-in-the-saddle（掌权中的）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 didnt see much likelihood that an error would be found. Today， we have MRI scans（核磁共振扫描）， ultrasound（超声波）， nuclear medicine， molecular（分子的）testing， and much more. When somebody dies， we already know why. We dont 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（有絡腮胡子的）and cheerful， a former engineer who had found success in retirement as an artist. I will call him Mr. Jolly， because thats what he was. He was also what we call a vasculopath（血管病患者）—he did not seem to have an undiseased artery（动脉）in him. Whether because of his diet or his genes or the facts that he used to smoke， he had had， in the previous decade， one heart attack， two abdominal aortic aneurysm（腹主动脉瘤）repairs， four bypass operations（搭桥手术）to keep blood flowing past blockages in his leg arteries， and several balloon procedures2 to keep hardened arteries open. Still， I never knew him to take a dark view of his lot（命运）.“Well， you cant get miserable about it，” hed say. He had wonderful children. He had beautiful grandchildren.“But， aargh， the wife，” hed go on. She would be sitting right there at the bedside and would roll her eyes， and hed break into a grin.

Mr. Jolly had come into the hospital for treatment of a wound infection in his legs. But he soon developed congestive heart failure（充血性心力衰竭）， causing fluid to back up into his lungs. Breathing became steadily harder for him， until we had to put him in the ICU， intubate（用插管法治疗）him， and place him on a ventilator（呼吸机）. A two-day admission turned into two weeks. With a regimen（养生法）of diuretics（利尿剂）and a change in heart medications， however， his heart failure reversed， and his lungs recovered. And one bright Sunday morning he was reclining（斜倚）in bed， breathing on his own， watching the morning shows on the TV set that hung from the ceiling. “Youre doing marvelously，” I said. I told him we would transfer him out of intensivecare by the afternoon. He would probably be home in a couple of days.

Two hours later， a code-blue（紧急抢救）emergency call went out on the overhead speakers. When I got to the ICU and saw the nurse hunched over Mr. Jolly， doing chest compressions（胸部挤压，用来保持病人呼吸的方法）， I blurted out（脱口而出）an angry curse. Hed been fine， the nurse explained， just watching TV， when suddenly he sat upright with a look of shock and then fell back， unresponsive. At first， he was asystolic（心搏停止的）—no heart rhythm on the monitor—and then the rhythm came back， but he had no pulse. A crowd of staffers set to work. I had him intubated， gave him fluids and epinephrine（肾上腺素）， had someone call the attending surgeon at home， someone else check the morning lab test results. An X-ray technician shot a portable chest film（胸片）.

I mentally ran through possible causes. There were not many. A collapsed lung， but I heard good breath sounds with my stethoscope（听诊器）， and when his X ray came back the lungs looked fine. A massive blood loss， but his abdomen wasnt swelling， and his decline happened so quickly that bleeding just didnt make sense. Extreme acidity of the blood could do it， but his lab tests were fine. Then there was cardiac tamponade（心壓塞）—bleeding into the sac（囊）that contains the heart. I took a six-inch spinal needle（脊椎穿刺针）on a syringe（注射器）， pushed it through the skin below the breastbone， and advanced it to the heart sac. I found no bleeding. That left only one possibility： a pulmonary embolism（肺栓塞）—a blood clot（血凝块）that flips into the lung and instantly wedges off（抵住）all blood flow. And nothing could be done about that.

I went out and spoke to the attending surgeon by phone and then to the chief resident， who had just arrived. An embolism was the only logical explanation， they agreed. I went back into the room and stopped the code. “Time of death： 10：23 A.M.，” I announced. I phoned his wife at home， told her that things had taken a turn for the worse， and asked her to come in.

This shouldnt have happened； I was sure of it. I scanned the records for clues. Then I found one. In a lab test done the day before， the patients clotting had seemed slow， which wasnt serious， but an ICU physician had decided to correct it with vitamin K. A frequent side effect of vitamin K is blood clots. I was furious. Giving the vitamin was completely unnecessary—just fixing a number on a lab test. Both the chief resident and I lit into（痛斥）the physician. We all but accused him of killing the patient.

When Mrs. Jolly arrived， we took her to a family room where it was quiet and calm. I could see her face that shed already surmised（猜測）the worst. His heart had stopped suddenly， we told her， because of a pulmonary embolism. We said the medicines we gave him may have contributed to it. I took her in to see him and left her with him. After a while， she came out， her hands trembling and her face stained with tears. Then， remarkably， she thanked us. We had kept him for her all these years， she said. Maybe so， but neither of us felt any pride about what had just happened.

I asked her the required question. I told her that we wanted to perform an autopsy and needed her permission. We thought we already knew what had happened， but an autopsy would confirm it， I said， as I was supposed to， that it would. I wasnt sure I believed it.

1. 阿尔茨海默病（AD）是一种神经系统退行性疾病，临床上以记忆障碍、失语、失用、失认、视空间技能损害、执行功能障碍以及人格和行为改变等全面性痴呆表现为特征，病因迄今未明。65岁以前发病者称早老性痴呆，65岁以后发病者称老年性痴呆。

2. 球囊扩张术，通过球囊导管介入来使硬化的血管扩张。