The First Cut
Ralph B. Freidin
"Just cut through," said Dr. Trotter, my anatomy professor.
I had read the instructions in her 1947 dissecting manual. My copy, purchased used, was preserved by stale formaldehyde and smudged with the tissues of past cadavers who'd guided earlier first-year medical students from anatomical landmark to anatomical landmark within the human body.
The time: forty-six years ago. The day: my first day of medical school.
The dissecting room was on the second floor of a building that had been new in 1927. The windows, opened to capacity, vainly invited in any breeze from the still St. Louis fall afternoon. The cinnamon aroma of dry sycamore leaves floated from the sidewalk to the windowsill before being repelled by the pungent embalming chemicals permeating the room.
Amid the sycamores' sweetness and the acrid formaldehyde, eighty-eight medical students stood beside forty-four black slate dissecting blocks on which lay black rubber body bags, suffused with formaldehyde. They held the preserved cadavers--our Charons, preparing to guide us on our three-month journey across and through the landmarks of the body, from the land of the living to the land of the dead. From there, each of us would be on our own to find a way back to the living.
The manual said: "1) Locate the right sternoclavicular joint; 2) Locate the right inferior costal margin at the anterior axillary line; 3) Cut between the two landmarks."
The directions were explicit. The landmarks easily identified. I plotted a path between the two points.
My hand, trembling with the scalpel, froze above my female patient's right sternoclavicular joint (where the near end of the collarbone joins the top end of the breastbone), unable to cut through and continue along the path to the lower lateral edge of my cadaver's right rib cage.
What was I to do with the breast that lay softly between the two anatomical landmarks? Push it to the side? Cut around, or under? Bisect the breast? Did I dare envision whose hands had caressed it, who first had nursed there?
Earlier that day, we had been instructed, "Respect the person your cadaver has been." Slicing through her breast could not possibly be respectful of the nameless body lying naked before me.
My right arm, hand and fingers would not put my scalpel into motion. I felt confused. Had I been assigned a male cadaver, would I have balked?
Feeling lost, desperate, I timidly stepped forward to ask Dr. Trotter for guidance. Her soft face and curled white hair reminded me of my first grade teacher; they belied the detached formality exuded by her starched white lab coat.
"Dr. Trotter, the instructions don't say what to do with the breast."
"Just cut through." Her answer was direct and as devoid of life as my cadaver. Three one-syllable words unknowingly imprinted every detail of that day in my memory.
It is not just Dr. Trotter's terse reply--"Just cut through"--that remains. It is the textures and aromas of that sultry day that control my memory of slicing between two points on a dead body, cleaving the breast that lay between, transforming an object of mystery into an anatomical specimen, leaving a yawning wound.
The still humidity of late fall or a pungent odor still have the power to evoke those images--and reawaken memories of another, earlier dissection.
Three years before I entered medical school, my mother, a statuesque woman, was transformed into a lopsided, ashamed shadow of herself. The doctor, vainly attempting to cure the cancer growing unseen in my mother's right breast, removed all traces of the breast and left a gaping wound under her right arm.
Now, decades later, I still vividly remember staring bewilderedly at the crater under my mother's right arm and the flatness of her right chest--the hardness of exposed ribs replacing the soft curves of womanhood, the emptiness under the right side of her blouse.
To this day, every time before performing a breast exam, I give myself three directions: 1) look directly at the patient's breasts from the front and sides; 2) feel each breast thoroughly while she's sitting and lying down, back arched over a firm pillow; 3) reach high into her armpit. If I do not deliberately follow these steps, the image of the surgeon's removing my mother's breast and dissecting deep into her armpit distorts my vision and numbs my fingers.
And whenever a patient describes the lumpectomy that cured her breast cancer, I hold my breath, tasting tears for my mother, who suffered the consequences of the medical ignorance that prevailed a half-century ago, when radical mastectomy was the treatment--rarely the cure.
Then I tell the patient, "That's wonderful," and deflect the conversation elsewhere.
"Dr. Trotter, your instructions don't say what to do with the breast. Do I cut around?"
Did it even occur to her--she, who had made a career of looking under the skin for answers to medical questions--to consider what was under the skin of mine?
About the author:
Retired after thirty years of practicing primary-care internal medicine in Lexington, MA, Ralph B. Freidin is an attending physician emeritus at the Mount Auburn Hospital, Cambridge, where he continues on the Ethics Committee. He currently teaches medical students at Boston University Medical School and Harvard Medical School. "Encouraged by a poet friend, I started writing poetry eight years ago and discovered a way to express the many feelings experienced in the relationships I had formed with my patients." His other interests include health care as a right for all citizens (as a medical student, he established a neighborhood health center) and advocating for Obamacare and a national health program. He also volunteers around the country at mega-clinics for Americans without health insurance. His blog istheunseenpatient.blogspot.com.