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In a Medical Sanctuary

Jean Gaumy/Magnum Photos
Doctors and interns in a pediatrics ward, Le Havre, France, 1975

A doctor’s education classically begins with an introduction not to the living but to the dead. And so it was for me some forty years ago. After the opening lecture on human anatomy in a large amphitheater, our class moved to a cold subterranean room. There, scores of cadavers covered by plastic sheets lay on stainless steel tables. The pungent smell of formaldehyde filled the cavernous space.

We were divided into groups of four, each group assigned a body. As a fellow student lifted the plastic sheet, I saw a female of indeterminate age with bronze-colored skin, a taut belly, and puckered breasts. Age was hard to ascertain because the bodily features we focus on to recognize individuals—face and hands—were covered in tightly wrapped gauze. The instructor directed our attention to the arm, and I made a tentative first cut with a scalpel to open the skin and expose the biceps muscle. Over the ensuing weeks, we marched across the limbs, meticulously dissecting muscle and nerve and tendon, tying fine strings around each isolated part with a small tag to identify the structure. Ultimately, we reached the boundaries of the exposed skin, and were told to remove the gauze coverings. My cadaver’s head was crowned by matted gray hair and her hands were fine and boney, the knuckles distorted by arthritis. We made precise incisions and exposed the muscular splay of the palm.

It was a late autumn afternoon when we completed the dissection, and as I walked along Fort Washington Avenue to the dormitory, I glanced down and saw something on the toe of my shoe. At first I didn’t know what it was, and then realized that a thick clump of flesh had fallen from my cadaver. I stood motionless for a long while. I felt as if I had committed a sacrilege, violated a boundary, by removing the dead from a proper hidden place.

I thought how the cadaver was intentionally masked so as not to be a person. And how the dead were distant to me. No one I knew had died, and I had never been to a funeral. My mind in the dissecting room had been fully occupied with recognizing the shapes and locations of anatomatical parts. Now, I was gripped by the sense that I must be much more than simply these parts, that I had a dimension distinct and above the physical. But might the reductionists be right? Was I in the end merely a mass of interacting molecules, and my sense of self, the conscious perception of an existence beyond the material, an illusion?

The anatomy laboratory was locked after each dissection, so I slowly retraced my steps, careful not to dislodge the piece of flesh, back from Fort Washington Avenue to a small garden behind the medical school. There, I took a leaf and detached the fragment and then covered it with a thick layer of earth.

That was the first time medicine had brought me close to mystery. And over the ensuing decades as a physician, I experienced more such moments, as an intimate witness to life’s great mysteries: the sudden arrival of new life at birth; the perplexing passage to death; the desperate desire of patients to find meaning in illness. Did each moment offer a glimpse of the soul, its arrival, its departure, its struggle? And what might a physician learn from those times about his own life?

Victoria Sweet opens God’s Hotel, a beautifully written and illuminating book, with an experience of wonder similar to mine. She is not in the anatomy lab but in the autopsy suite, and recognizes a patient, Mr. Baker, whom she had treated:

I watched as the pathologist set to work with his electric saw. He opened the chest wall and removed the soggy, honeycombed lungs. He weighed them each separately, first the right lung, then the left. Then he took out the large and heavy heart, with its right side hypertrophied from lung disease, and documented its weight in grams. Next he opened the abdomen and ditto the liver, the spleen, the pancreas, the kidneys. Each organ was removed and weighed, and its weight in grams tallied. The blood vessels, large and small, were inspected and commented upon. Then the saw attacked the head. Sure enough, there it was—the brain—looking just like it did in the books, gray, spongy, with a texture kind of like pâté—homogeneous, boring. Then Mr. Baker was done. We were done. Finished. That was it. Nothing more inside.

Sweet then explains why this experience left her “strangely disappointed.”

There was nothing else to see. No hidden place, unexplored and unexplorable, no unopenable, small black box, hidden in all those wiggly intestines. It was undeniable—Mr. Baker had completely disappeared. Autopsied, his body was nothing more than a suit of clothes lying disregarded in the corner.
Something was missing. But what? Mr. Baker’s breathing? His movement? His warmth? What I had expected, I later came to realize, was some sort of thing, some unopenable last nubbin, like what you find at the center of a baseball when you unroll it. I had expected some thing that was, well, ineradicably Mr. Baker, something the pathologist’s saw could not open and destroy. But there was no such thing; I could see for myself.

What might the thing be that Sweet expected to find? Deeply grounded in Christian concepts, she writes that the Latin spiritus, from which we get the English “spirit,” was not as insubstantial as “spirit.” “Spiritus was the breath, the regular, rhythmic breathing of the live body that is so shockingly absent from the dead. Spiritus is what is exhaled in the last breath.”

Sweet’s Latin exegesis can be traced back to the Genesis narrative of human creation. “Adam” comes from the Hebrew word for earth, how human life began when God breathed into the dust of the earth. The term for “spirit” is ruach in Hebrew, a synonym for wind, and “soul” is neshama, derived from the word for “breath.”1

But what Sweet ultimately seeks is anima, a life force with an Aristotelian resonance:

And there was anima. Usually translated as soul, the Latin is better for conveying the second striking distinction between Mr. Baker’s dead body and Mr. Baker—its lack of movement. Because anima is not really the abstraction, “soul.” Anima is the invisible force that animates the body, that moves it, not only willfully but also unconsciously—all those little movements that the living body makes all the time. The slight tremor of the fingers, the pounding of the heart that shakes the living frame once a second, the gentle rise and fall of the chest. Those movements by which we perceive that someone is alive. Anima, ancient medicine had observed, is just as absent from the dead body as spiritus.

As with many doctors with a liberal education, Sweet’s pondering of philology and philosophy recedes in the presence of physiology and pharmacology. Her daily tasks are clinical, where science prevails:

During all those years I was ever more impressed by the power of modern medicine—by its logic, its method for arriving at a diagnosis and a treatment. Yet every now and again I had other experiences like that with Mr. Baker—experiences that left me wondering…. All evidence of some subtle but shared world, where beings popped up and disappeared, of invisible connections with visible effects.

Victoria Sweet served as a physician at Laguna Honda, the last almshouse in the city of San Francisco, and perhaps in the country. Its French equivalent was Hôtel Dieu—God’s Hotel. Supported by the city of San Francisco, Laguna Honda accepted all in need, or as Sweet puts it, those who had “no other place to go.” Of course, there were other places where they had been: on the streets, sleeping in cardboard boxes or beneath highway underpasses, or in filthy tenement apartments and SROs, where they were neglected or abused, or abused themselves through drugs and alcohol.

Such patients typically are the bane of interns or residents, depicted in Samuel Shem’s The House of God (1978), a roman à clef about a Boston teaching hospital. In that novel, read by virtually every doctor I’ve known, Shem charted the trajectory of the many interns who arrive idealistic, with a humanistic vision of medicine, and end their first year of training bitter, cynical, depressed, and mercenary. The word used by Shem’s young doctors for the elderly demented and debilitated patients is “GOMERs” (Get Out of My Emergency Room). The doctors feel that they can’t do anything for the GOMERs. (They should be “turfed,” transferred out of your charge as quickly as possible.)

God’s Hotel is the counterpoint to The House of God. Instead of becoming alienated from those who arrive in old filthy clothes, malnourished, confused, or delusional, Sweet draws ever closer to them. She takes on each case looking for clinical clues about an underlying problem whose remedy might improve the patient’s condition. For example, in one chapter where she oversees a ward populated by the demented, Sweet does not blithely accept the convenient label of Alzheimer’s disease that was fixed onto her charges. Rather, she looks for conditions like abnormal thyroid function or B12 deficiency and especially overmedication with antipsychotic drugs or tranquilizers that could explain the blank faces and slurred words and episodes of delirium. Occasionally she discovers such remediable problems, and restores a patient to an aware and meaningful life.

In her acknowledgments Sweet thanks Oliver Sacks as an early reader who encouraged her, and she expands on the approach that Sacks took in An Anthropologist on Mars (1995). Sacks’s focus is on adaptation; he seeks to understand how each person’s clinical condition connects with his or her environment. He journeys to the home of a physician with Tourette’s syndrome and to the workplace of Temple Grandin, a veterinary scientist with Asperger’s syndrome. Victoria Sweet is also an anthropologist of sorts, but one who explores the unique environment of Laguna Honda.

At this hospital there are antibiotics and anti-arrhythmics, surgeons and radiologists, the latest technology and treatments. But its world sharply differs from what we know as “modern medicine” not only in space, with large open wards, but in time. There was no imperative to diagnose and treat a patient quickly, no administrator trolling through the wards checking “length of stay,” a merciless metric that pushes patients out the door so that the institution is paid well. Rather, as Sweet describes, there was “slow medicine,” time to observe and think. Ironically, as she repeatedly shows, patients sent to Laguna Honda after having been “turfed” by desperate doctors elsewhere received better care than could be given in other clinical settings. Sweet argues that the worlds these people inhabit are destructive and daunting, too difficult to meaningfully change. What is needed then is sanctuary, a safe place, where they are protected from the pimps who beat them and the landlords who shut off their heat, the thieves who steal their welfare checks, the drug dealers who supply their habits, and the families who neglect them.

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    Islam uses similar Arabic terms: al-Nafs is the soul, with Nafas meaning “breath”; al-Ruh is the spirit, related to “wind.” The Ruh and the Nafs are both inexorably linked to the physical body, yet remain distinct from it. At the moment of death, they break this bond by leaving the body, which is described like a thorn being pushed through a cloth—the cloth resists and strains for a moment, then the thorn suddenly pierces clean and free through it. 

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