In between life and death

The art of medical history shows the precarious position of physicians.

By Jonathon Keats
Published April 6, 2000 4:00PM (EDT)

We live, and we die. In between those two extremes lies medicine.

Physicians, rather like diplomats, must be on familiar terms with both human states in order to be effective partisans of either. Doctors must go places we'd ourselves like to avoid. They must keep a certain confidential manner. Tempted as we may be to view the history of medicine as a story of advancement from brute savagery to HMO-facilitated immortality, the evidence left behind over the past millennium -- textbooks, scalpels and apothecary jars -- suggests, rather, the pains physicians have invariably taken to conceal from their patients what they can't help but acknowledge among themselves: the morbid neutrality of their trade.

Then along comes the Duke University Medical Center with what looks to be a scholarly exhibition, but in fact is an act of high treason. The curators have innocuously titled it "The Physician's Art," and published on the occasion a book-length catalog handsome enough to mingle on a coffee table with the likes of Vanity Fair.

But don't be misled by the matte satin stock. By collecting in one place medical-school mannequins and gross anatomy primers and the tools and tinctures with which the machinery of health has been primed ever since Andreas Vesalius first put blade to cadaver in the 16th century, the exhibition and catalog open up a whole doctor's bag of questions about the compromises the physician must strike between life and death if he's to maintain free passage across the pathways of medicine.

As straightforward as medicine may seem to the patient -- merely something to be bottled and swallowed -- the doctor engaged in the art of diagnosis and treatment must at every turn consider a whole history of trial and error.

Obviously, the dead play a crucial role in medical practice: Doctors look to the cadaver for knowledge (pathology) and patients rely on the deceased for spare parts (transplants). What becomes apparent in "The Physician's Art," though, is the ambivalence with which the physician must treat the barrier we like to think separates us from our corpses: To view the imagery with which doctors have historically shared their wisdom with one another and to compare it to that revealed to patients is to see that, confident as their diagnoses may be, for physicians the real distinction between life and death is one of degree, not kind.

It's a viewpoint that lies at the very foundation of modern medicine. In the first place, there's Vesalius himself, who single-handedly toppled 1,200 years of conventional wisdom about the human body when, at the age of 29, he published "De humani corporis fabrica." His 1543 treatise stood apart from all anatomy books that preceded it because his knowledge came from the dissection table rather than the ancient Greeks.

Vesalius was a scientist. Whereas the Greek anatomists had conjured their image of the human body by assuming correspondences to the animals they commonly dissected, he made his discoveries by cutting open the human cadaver. In other words, rather than assuming similarities between species, he placed his trust in correspondences between the living and the dead -- an act approaching sacrilege in a religious atmosphere that sought to find life not in the flesh but in the spirit. The wood-block plates that accompany "Fabrica" boldly illustrate Vesalius' faith in the common ground held between living and dead. The frontispiece shows him conducting a demonstration in a theater crowded with young and old.

But most prominent of all -- more central than Vesalius himself -- is a human skeleton, bearing a wooden staff, overseeing the grisly operation. Within the book, his skeletons are even more animate, situated in the landscape in poses so natural that they might be taken as members of some extreme nudist colony.

There's something singularly demonstrative about their gestures: Like nudists, the dead have a lesson to teach. In Vesalius, the deceased instruct the physician about life, and the lesson reaches its logical conclusion in the Latin inscription on the grave marker against which one of the more contemplative skeletons leans: "What I am now, you will soon be."

But, for the physician, even that wasn't sufficiently promising. More to the point was Juan Valverde de Amusco's "Anatome corporis humani," a book significantly smaller and, in consequence, cheaper than Vesalius' magnum opus. Less scholarly, and available in Spanish as well as Latin, Amusco's 1607 text was just the sort of Cliffs Notes to "Fabrica" eagerly sought by 17th century medical students.

While many of Amusco's images are copied from Vesalius' book -- the "illustrations are so well done it would look like envy or malignity not to take advantage of them," he confessed in his preface -- those that are his own carry his most powerful message. A flayed muscle-man holds in one hand his skin and in the other a scalpel. A physician dissects a cadaver to show the position of the heart, a secondary view provided by his own chest cavity, rent open to show two healthy lungs behind a butterflied ribcage. He's not of the dead. (Unlike the blind eyes of the cadaver he's dissecting, his have pupils.) But neither is he quite of the living. (His pupils focus not on the cadaver or even his own impossibly open chest, but rather gaze heavenward.)

The obvious reference is to the popular moral "Know thyself," but in Amusco's image we see that the self in question, the physician, knows what he does by wavering between living and dead -- by becoming a creature able to pass in both worlds, without belonging clearly to either.

It's a hard lot, being a physician, and all the more difficult given that the patient's well-being depends on not knowing the full extent of the diplomatic crosscurrents between here and the hereafter. Better to discuss ailments over carved-ivory anatomical mannequins such as were common in the 17th century. As finely wrought as religious art of the era, these miniatures of the human body, popularly used by doctors to discuss ailments with their patients, lay on wooden beds, heads at rest on lace-frilled pillows, eyes shut as in sleep. Some had pullover ball gowns, and all were given removable chest plates, beneath which were revealed vital organs of carved ivory.

Women were carved complete with fetus. (The umbilical cord was fashioned from red string.) While they share anatomical properties, these trinkets have little else in common with Amusco's open-torsoed physician: These ivory chests come off as just another garment; dissection is like getting undressed. The resting mannequins reveal nothing to themselves, nor even -- as with Vesalius' skeletons -- to us. They sleep calmly while we, the lay public, look inside them, as a deity might see inside our own living bodies. They live on, and nobody is the wiser.

Probably it's healthiest that way: We sleep like mannequins while, on our behalf, the physician negotiates with life and death. We sleep, somewhere between here and there, believing we'll wake up again. And sometimes we do.

Jonathon Keats

Jonathon Keats is an artist and writer. His collection of fables, "The Book of the Unknown: Tales of the Thirty-Six," was published this year.

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