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msJAMA
March 6, 2002

Identification/Chief Complaint

Author Affiliations
 

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JAMA. 2002;287(9):1184-1185. doi:10.1001/jama.287.9.1184-JMS0306-7-1

Patient is an 88-year-old male who presents having been
Immersed in formalin for over a year. Though some would call him
Well-preserved, it does not accurately reflect his state.
Patient is unresponsive to questioning. No significant history can be
Elicited. One might say, though we are told not to, that the patient is a poor historian.
We are told instead that we are the historian, and that if
A poor historian is present, he is often wearing scrubs or a stethoscope.

Review of the chart shows patient had an arrhythmia for six months, eventually fatal,
Preceded by atrial fibrillation of two-year duration. Three year history of severe
Aortic stenosis. CAD ten years. Chronic renal insufficiency. Hypertension, CHF,
Peripheral vascular disease, venous insufficiency, DVT, degenerative joint disease,
Raynaud's phenomenon, depression, and hypothyroidism. Scars include 7-inch vertical at
Right hip and 3 and a half inch diagonal at appendix.

Upon inquiry into his identity and past history, I receive mail from the curator.
(I was an art historian and to me a curator is concerned with physical
Care and presentation of an object, but may also be an historian.
Curate, meaning care for, shares a Latin root with cure. Body appears cured.)
The curator shares an uncommon name with my sister and e-mails me to say

Hello Matt,
I'm sending some personal information on your cadaver. It is very unusual
That we would have this much information on a donor, but there was a
Brief biographical sketch in his donor file, so perhaps he "knew" that
You would be asking. . . . Nathan, your donor, was born in Illinois in May of 1911.
His father was also born in Illinois; his mother was born in Texas. Nathan had been
Widowed for many years, but had four children—three sons and a daughter—
and five grandchildren.

As a young man, he lived and received part of his education in Europe.
He later attended a prep school in Vermont. He was successful in business,
And had his own manufacturing business in Illinois. He was very proud of his family,
And his children's accomplishments. Nathan spent most of his adult life in Illinois.
One of his children lives in Maryland; two in New York,
and one son in San Francisco. Perhaps it was because of the son in
San Francisco that Nathan came to California.
I hope this information is helpful to you, Matt.
Regards, Dori

Upon physical exam, patient is extremely thin, with an upper arm easily
Encircled by my small right hand. His hands and head are swaddled in
White muslin and plastic bags, like Magritte's drowned mother, a suicide
Found with her nightdress veiling her head on the banks of the river Sambre.
His father was a salesman, too. On removal of the plastic bag and muslin
Covering the head, eyes are sunken, teeth are absent, expression is sour,
Patient appears judgmental, perhaps dissatisfied with the care he has received.
Three days beard growth lines his cheeks. Integument is compromised at
Right jugular vein, 1 centimeter superior to the clavicle and in the right inguinal area.
Sutures of coarse string in each area close a deep laceration.
Penis is circumcised, limp, and shrunken.
Upon palpation, his abdomen is cold and dense,
As if waterlogged. Limbs appear heavy, as turgid as the belly.

How can we lift things with arms that are themselves such slaves of gravity?
He appears Jewish, for no other reason than he wears my great-grandfather's nose,
Maybe his expression too. Countertransference discussed and noted. He appears in my
Dream that night and sees me, is clearly aware of me cutting into the skin
Over his heart, though he remains motionless and unresponsive. Should I apologize?
Thank him? Ignore his attention? In the end I decide to pretend all is
Normal and ask him routine intake questions. Any previous surgery? Family
History of heart disease? Do you get around OK? Were you breast-fed?
As a baby, did you learn to crawl early, or did you refuse to turn over
When set on your back, as I find you today? Better this dream than the one
Where a child has drowned and I cannot remember CPR.
Better to ask unanswered questions of the dead than to clog your lungs with
Sea water in a wrong-headed attempt to breathe a stranger's breath for them.
When I left art history for medicine, I thought I had
Relinquished the job of polling the dead. I committed to
Forty years of salt on my lips.

As the exam progresses, patient appears markedly worse.
Pneumothorax of a stupefying extent. Rupture of the great vessels.
His foramen ovale breaks open again, returning his heart to a state it hasn't
Seen in ninety years. I crack a rib during examination of the heart. Maybe two.
I accidentally rupture the inferior vena cava. I tear the left vagus or the left phrenic
Or both. Bowels are intact, though stained a Crayola green near the gallbladder.
Each night they return to their original configuration, since I'm afraid he might
Feel violated by any rearrangement. Duplication of the right ureter noted.
Examination of the pelvis reveals the first irreversible disfigurement:
Each leg is separate from the torso, split from its twin,
As Sacks' ‘Man Who Fell Out of Bed' put it, "Like nothing on earth."

Extremities are emaciated but structurally normal. Palmaris longus is absent, but that's
A finding, not a diagnosis. I discover with some regret that I feel satisfaction at
Having sawed through his cheek, his mandible,
At the name and the use of rongeurs. Further examination reveals a hemisection of the
Cranium. I keep the left side: reason and language live there, at least in men.
I have a difficult time handing his emotions, his spatial abilities to the woman
One table down the line. Brain appears intact, with no visible masses, infarctions, or
Atrophy. Resemblance to marine life noted. No thoughts, emotions, or sensations
Apparent on surface examination of cortex. Salty taste on examiner's lips noted
Once more. Lacrimal gland easily visualized and
Palpated. Contains no tears.

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Note: Please send murmur submissions (personal essays, fiction, or poetry on either medical or nonmedical topics) to Teri Reynolds at treynol@itsa.ucsf.edu.
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