Ostler, Skulls and Autopsy

Ostler, Skulls and Autopsy

By John Taylor; 2006 August 13

Autopsy: 1: an examination of a body after death to determine the cause of death or the character and extent of changes produced by disease 2: a critical examination, evaluation, or assessment of someone or something past

On Wednesday I picked up Fran Laner in Cayuga, and then drove on to Simcoe where we represented our LSA in a joint cluster meeting on behalf of the persecuted Baha'is in Iran with Diane Findlay, our Member of Parliament in Ottawa. It was a pleasant meeting; the Baha'is met together beforehand in a coffee shop and practiced what to say. Then we presented the MP with a copy of the Hidden Words, somebody describing it as "inspirational stuff," and she replied that "we all need that..." Fran told a story of the present hour in Haifa -- that the shrines are being kept lit two hours longer during the blackouts in order to help keep the people of Haifa's spirits up during this crisis. The terraces are lighting up a dark city, and apparently it is an awe inspiring sight. The MP was duly impressed.

It was Tomaso's birthday the next day and I was directed to a toy store called "The Toy Box," where I bought him a pump action rocket and a multi-tool for camping. On the way Fran described her usual ideas which I can only describe as flakey -- a Chinese researcher demonstrates physical effects in water if it is prayed for before looking into the microscope. In my book that is superstition, plain and simple. Anyway, her gullibility emboldened me to try to verbalize my own flakey ideas about hillside housing. I talked about it the whole way back to Cayuga. I was not wrong, she was far from critical but quite supportive and I realized after my long explanation that this was the first time I had described the proposal to someone who was not already a reader of this Badi' list.

From the time I got home from Simcoe until now I have been laid up, miserable, and at times quite nauseous with a sort of cross breed between garden variety migraine and a mild flu. Yesterday I felt stronger but, uncharacteristically, was not up to writing and only scanned in some more material on the Master.

Much of the time over the past days I have been wading through a thick biography of William Ostler by medical historian Michael Bliss. This particular book was written in 1999 (I remember reading the reviews at the time), then was bought by some rich fellow who died and donated thousands of volumes to the Dunnville Public Library; they accepted the donation but kept most of the books only a couple of years and now are remaindering hundreds of the less popular ones. Note to self: do not donate books to a public library when you make up a will. Going over thousands of books in this year's summer long HCPL book sale, this book grabbed me, and not only because nobody, in all the couple of years it was in the library, had bothered to take it out. I started it and could not put it down, even through this period of illness. It is a real achievement; this is one of the best biographers I have ever read.

It is interesting to witness how Ostler got into medicine. At the time being an amateur naturalist was much more common, and it was more common for amateurs to contribute to the literature. Plus, there was more nature to go around. The cool tool of the time was the microscope, like the personal computer is today. Ostler became the equivalent of a microscope hacker, and since at least one of his mentors was also a doctor, the transition into medical school could not have been more natural. Then there was the dead house. In his early years at McGill in Montreal Ostler performed almost a thousand autopsies, and the book is full of anecdotes about the lengths to which he went to get more material to cut up. Most of it was illegal, or legal but vigorously opposed by the family of his slab fodder.

Ostler was so enthusiastic that, well, an anecdote: once he was called to give an autopsy at the rural home of a boy who had died of something horrible. When Ostler arrived he found that the parents had changed their minds and buried him. The family doctor whispered something in the father's ear and the family and neighbors went out, exhumed the body and laid it on a table in the barn. They all crowded around with dour faces and Ostler, with his characteristic enthusiasm cut the body open and explained everything he found inside to the unhappy audience. He was such a brilliant teacher that towards the end they did not appear unappreciative of what he was about. Later Ostler asked what the doctor had said to change the father's mind. "I told him that if they did not comply, I would foreclose on their farm." Then there were the incidents that are perhaps inevitable if you do a thousand autopsies: once a French Canadian resident exclaimed, "Hey, what for you cut open mon oncle?" Another assistant discovered that next up to be sliced apart was his naked, deceased grandmother. Talk about traumatic entry into your chosen profession!

At that time the microscope was coming into its own as the main tool for doctors and it stayed that way for decades; I searched way back and recalled my earliest remembered visit to a doctor, it must have been in the early sixties. He took a tissue sample, put it on a slide, looked into his microscope and pronounced his diagnosis. He said I would live, and as you see, I did. That was the last time, and I have seen many doctors through the years, that I have ever seen one actually use a microscope. Now of course they send everything out to labs.

Plus, I read in the newspaper that the autopsy is no longer done as much as it used to be, and that this is a pity because, as Ostler's career demonstrates, autopsies are a form of quality control, the only really sure way to know how well a doctor did his or her job when the patient was alive. Now the family doctor leaves research and quality control (cutting up corpses is legal now but it remains just as icky) to professional researchers, which is a pity. I think this is a form of credentialism, or just brazen laziness; ultimately it betrays the scientific aspirations of physicians and plays into the hands of quacks and drug mongers. If we all have to die is it not right that our physical condition should be checked very carefully and the data kept so that posterity can analyze it and better understand what killed us, and what kept us alive? Information storage and silicon memory are cheap and getting cheaper every day, so retaining masses of such data is not the problem it was even ten years ago. Having an autopsy upon death should be a universal right, privilege and duty in this day and age, for it is one of the few things that can contribute to giving every death, be it quiet or violent, a certain meaning and value. If expense is an issue, maybe video equipped robots could be constructed to perform autopsies twenty four seven. They make cars, so why cannot they deconstruct our bodies before they are recycled?

Philosophically, the very word "autopsy" is meaningful. It did not even become an English word until 1678, mostly because religious taboos forbade the practice -- for good reason since it is easy for disease to spread this way unless one knows how to do it and is very careful. Ostler's hands were covered with cysts from a communicable disease caught from constant contact with corpses; until he went to pioneering Johns Hopkins, wearing gloves was not accepted practice. In any case, the word "autopsy" comes from the Greek "autopsia," meaning the "act of seeing with one's own eyes." Is not that the universal duty of every Baha'i, of every person in this age, to investigate the truth with our own eyes, at first hand? Is it not required of us every day to examine our actions that day, as in a self-conducted post mortem? Do we not, at least the believers among us, expect upon death to have God perform an autopsy on our soul?

Thoughts in this direction lead me to wonder why other professions have not taken up the autopsy, especially teachers. Sure, it is not nearly as easy to cut open a mind later on to see if a certain teaching method worked as it is to hack away at a cadaver to confirm a diagnosis or treatment, but some sort of effort should be made. At the very least, the performance of a given school and teacher should be measured by statistical performance checks on the careers of their old students. Teachers should constantly check their long term effect on students by investigating directly how former students did after graduating, through interviews and group consultations. These should be recorded for posterity and carefully viewed and assessed by up and coming student teachers along with their teachers, as a running commentary by an expert is an essential part of a medical autopsy.

In view of all this, I think the Hippocratic Oath is a much more important document than most people, even doctors, imagine. It starts off talking about teachers, with language reminiscent of Baha'u'llah's law that one offer part of one's legacy to one's teachers:

"I swear ... that ... I will keep this Oath and this stipulation- to reckon him who taught me this Art equally dear to me as my parents, to share my substance with him, and relieve his necessities if required; to look upon his offspring in the same footing as my own brothers..."

If every profession had that attitude, I very much doubt that teachers would have much problem getting former students to at least give them an interview or "teacher's autopsy" as it might be called every decade or so. But first teachers would need to have a longer term concern for advancing their profession than now. In view of that, take a look at the definition of autopsy that begins this essay. Notice that it does not include an essential reason for performing autopsies, not only to understand disease, but to be able to understand normal anatomy, the lack of disease. In the same way, a teacher needs to see not only what leads to success but also what leads to failure, and mediocrity, and everything between and among them, in order to be a wholly competent teacher and advance the teaching profession. Anyway, the oath continues with what must be the first hint at what is now called "open systems" or open copyright laws.

"(I swear) ... to teach them this art, if they shall wish to learn it, without fee or stipulation; and that by precept, lecture, and every other mode of instruction, I will impart a knowledge of the Art to my own sons, and those of my teachers, and to disciples bound by a stipulation and oath according to the law of medicine, but to none others."

This brings up the necessary self interest of every learned profession (I think trades should be included now, since every human job is learned in this day and age, and becoming more so every day) that Jane Jacobs talks about in an entire chapter in "Dark Age Ahead," a protective attitude to one's fellow practitioners that, within reasonable limits, is necessary for the functioning of society and is distinct from corruption, which comes about when a profession fails to self-regulate (and that means, as it were, performing autopsies on their own bad apples, and learning from them). Jacobs edited an architectural journal for a decade and mentions that her publication never criticized the work of other architects, though it did studiously ignore the worst monstrosities. This refusal to backbite is generalized for everybody in Baha'u'llah's law, and it also is enshrined in the duty of doctors to keep privileged certain personal information that comes their way in the line of work, as found in the Hippocratic oath:

"Whatever, in connection with my professional practice or not, in connection with it, I see or hear, in the life of men, which ought not to be spoken of abroad, I will not divulge, as reckoning that all such should be kept secret."

As I read Ostler's story I constantly bear in mind a recent study that found a "sweet point" for the competence of physicians of six to eight years after graduation; at this time their experience is ample enough to supplement a body of knowledge that is not yet obsolete. After that point accumulating experience fails to balance out the obsolescence of their technique and schooling. If that is so, I begin to think, why not retire doctors after twelve or fourteen years of practice in the same way that professional athletes retire? Even lawyers are encouraged to get out of lawyering after a while and enter politics or teaching; doctors should be subject to the same limits and controls based upon performance. A doctor who stays a practicing doctor after his competence has been compromised by age should be open to condemnation, if not by peers then at least from the general public. In effect, that is just what the closing words of the Hippocratic oath ask be done to unethical practitioners:

"While I continue to keep this Oath unviolated, may it be granted to me to enjoy life and the practice of the art, respected by all men, in all times! But should I trespass and violate this Oath, may the reverse be my lot!"

But on the other hand, I have been suggesting that teachers take a longer term view of their performance, and surely the same is a good thing for medicos too; it would be impossible to keep close tabs on patients over their entire lifetime if doctors only actively practiced for less than two decades. In the case of Ostler, he was still making some pretty hair raising mistakes even into his forties (being scrupulously honest, he recorded every one of them and tried to learn from them, which is what the true spirit of autopsy is all about), after which time he gained fame and became a "doctor's doctor," only looking at cases that interested him. He noticed that very often doctors came to him with severe crises, a sick child or wife, that they could have dealt with themselves if they only kept up on their reading of the recent literature. Thank God for the Internet! Now even patients can do that kind of reading without leaving their studies; the film "Lorenzo's Oil" tells how parents who were not doctors took on that job for themselves, just before the Internet's infinitely greater possibilities started to open up.

I glory in a near future when the technical aspects of diagnosis --all the snares and pitfalls that make for that sweet point between incompetence and obsolescence in doctors -- being taken over by group medicine, many experts working apart but connected virtually like the authors of the Linux operating system; the human you see in person then would act more as a coach or tutor who walks you through and bucks you up in crisis, and assures you that all that can be done is being done. This person backed up by computer connected experts would be trained to show what Ostler was a past master at showing to patients: an optimistic attitude, funny, wise, kind, saintly, moderate, frank, whatever a patient needs at that moment. Reading about how he did this is truly inspiring and has helped me get through my own little period of illness.

And with this brilliant biographer you get both sides of the story, the cases where he inspired and cured by mere force of personality, where he told the right joke to put a nervous or frightened patient at ease, as well as those less common cases where he stepped over the line. Like when he noticed that a head nurse was fanatical about hygene, so he went into the basement, snatched up a spider's web and challenged her on his discovery of a noticeable flaw in antisepsis. She immediately burst into tears and Ostler's wife had to come in later to apologize and explain that he was only joking. If the likes of me ever did such a thing I would be hated by all and a few interactions like that would surely end of career and reputation. But I am no Ostler.

Let me close with a quote from Ostler's favorite author, Thomas Browne. Ostler had Browne's "Doctor's Religion" practicably memorized and, bizarrely, at the end of his career he bought up not only several of Browne's rare first editions but even Browne's skull, with matching skull container, or whatever the word is for a skull holder. In doing that Ostler may well have had the following passage in mind:

"Whosoever enjoys not this life, I count him but an apparition, though he wear about him the sensible affections of flesh. In these moral acceptions, the way to be immortal is to die daily; nor can I think I have the true theory of death, when I contemplate a skull or behold a skeleton with those vulgar imaginations it casts upon us." (Sir Thomas Browne, Religio Medici)