剖還是不剖?

By Atul Gawande

The first documented postmortem examination（驗尸）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（多米尼加共和國）]， upon conjoined（連體的）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（洗禮）them as two separate souls. A disagreement subsequently ensued（接著發(fā)生）about whether he was right to have done so， and when the “double monster” died at eight days of age an autopsy（驗尸，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（苛評，責(zé)難）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（同謀犯）， 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（爆炸裝置）coffins” equipped with pipe bombs（土制管式炸彈）rigged（裝備）to blow up if they were tampered with（胡亂擺弄）. Yet doctors remained undeterred（未被嚇住的）. 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（肺結(jié)核）， reveal how to treat appendicitis（闌尾炎）， and establish the existence of Alzheimers disease1（阿爾茨海默病）. 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（歸因于）this to shady（陰暗的）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（治療不當(dāng)）. And yet autopsies lost money and uncovered malpractice when they were popular， too.

《醫(yī)生的修煉：在不完美中探索行醫(yī)的真相》（Complications： A Surgeons Notes on an Imperfect Science）是一本真實的醫(yī)生手記，記錄了作者葛文德從見習(xí)生到一名成熟老練的外科大夫的經(jīng)歷。書里對外科手術(shù)精準(zhǔn)入微、觸目驚心的描寫讀起來令人有些毛骨悚然，然而這些描寫也是本書的精華。作者的筆猶如犀利的手術(shù)刀，在觸及病人痛處的同時也觸動了讀者的內(nèi)心，引起讀者對醫(yī)生行業(yè)倫理的深度思考?！稌r代周刊》評論葛文德“有一支犀利如手術(shù)刀的筆，一雙如X光般具有穿透力的眼睛”，而他描述的每一個病例故事，“從槍傷到病態(tài)肥胖到噬肉菌，都是迷你驚悚小說……這是一本讓人目不轉(zhuǎn)睛、不忍釋卷的精彩之作?！北酒诠?jié)選了書的開頭部分，作者描述了過去醫(yī)生們對驗尸的熱衷和民眾對驗尸的看法。一開始作者認(rèn)為有了現(xiàn)代醫(yī)學(xué)設(shè)備和技術(shù)后，驗尸的實用性已經(jīng)大大下降，然而一次意外的治療經(jīng)歷改變了他這個看法。

Instead， I suspect， what discourages autopsies is medicines twenty-first-century， tall-in-the-saddle（掌權(quán)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（核磁共振掃描）， ultrasound（超聲波）， 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(luò)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（動脈）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（腹主動脈瘤）repairs， four bypass operations（搭橋手術(shù)）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（命運）.“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（用插管法治療）him， and place him on a ventilator（呼吸機）. A two-day admission turned into two weeks. With a regimen（養(yǎng)生法）of diuretics（利尿劑）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（緊急搶救）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（胸部擠壓，用來保持病人呼吸的方法）， I blurted out（脫口而出）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（腎上腺素）， 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（聽診器）， 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（脊椎穿刺針）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（血凝塊）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. 阿爾茨海默?。ˋD）是一種神經(jīng)系統(tǒng)退行性疾病，臨床上以記憶障礙、失語、失用、失認(rèn)、視空間技能損害、執(zhí)行功能障礙以及人格和行為改變等全面性癡呆表現(xiàn)為特征，病因迄今未明。65歲以前發(fā)病者稱早老性癡呆，65歲以后發(fā)病者稱老年性癡呆。

2. 球囊擴張術(shù)，通過球囊導(dǎo)管介入來使硬化的血管擴張。