Posted on 03/22/2004 10:53:18 PM PST by neverdem
Over the centuries, dissecting the human body has evolved from a criminal offense to a vehicle of mass entertainment to an initiation rite.
In the Middle Ages, human dissections were forbidden. In 17th century Europe, medical school dissections were open to the public and often attracted unruly crowds cracking obscene jokes. By the 20th century, dissection had become the exclusive purview of scientists and a mandatory rite of passage for all doctors.
The scandals reported this month with donated cadavers at the University of California, Los Angeles and Tulane University are simply the most recent in a field long beset by abuses.
In 18th and early 19th century America, the public repeatedly rioted against doctors and medical institutions accused of dishonoring the dead. In 1878, the body of Senator John Scott Harrison (the son of President William Henry Harrison) disappeared from its Cincinnati crypt, only to surface in the dissection laboratory of a local medical school.
Now, though, the place of dissection in medical education is changing in ways that have not been seen before.
The hours devoted to formal anatomy training are sharply down in medical schools. Anatomy instructors are in short supply. Computerized scans and three-dimensional recreations of the human body provide cleaner, more colorful teaching tools than the time-consuming dissections of the past.
Some educators say that dissection, as taught to medical students since the Renaissance, is on its way out. Others maintain it is becoming more important than ever, not only for teaching the structure of the human body but also for the more subtle lessons it can impart on the meaning of being a doctor.
"It is always difficult to decide how much anatomy should be learned by a doctor," said Dr. Frank Gonzalez-Crussi, a retired pathologist in Chicago who has written extensively on the history and philosophy of human dissection.
Much of the traditional anatomy curriculum is irrelevant to medical practice and might easily be eliminated, Dr. Gonzalez-Crussi said, but there is still no substitute for dissection, which forces the student, willy-nilly, to confront human mortality.
Through the mid-20th century, medical students typically spent hundreds of hours dissecting. Working in small groups with scalpels and scissors, they would tease out every major structure in the body, including tendons, arteries and nerves, memorizing dozens of tortuous pathways and hundreds of Latin names in the process.
But as the focus of medical science has shifted from whole organs to cells and molecules, more and more teaching hours are consumed by molecular biology and genetics.
"Something has to give somewhere," said Dr. Arthur F. Dalley II, director of medical gross anatomy at the Vanderbilt School of Medicine.
That something has been anatomy. Surveys show that today's medical students may spend more than 80 percent less time in dissections than did students in the 1950's. The personnel to teach anatomy courses have declined in parallel: anatomy faculty members are aging, Dr. Dalley said, and fewer classically trained graduate students are available to replace them. In many universities, anatomy departments have been engulfed by other departments in the biological sciences.
A shortage of donated cadavers is not the big problem. Most medical schools receive enough to meet their teaching needs. Anatomical research continues to have practical applications, for example, in the design of new implants or prosthetic devices. Still, startling new discoveries in anatomy are uncommon, and money for research is sparse.
"It seems that anatomy has fewer and fewer advocates," Dr. Dalley said.
To supplement dissections, medical schools now routinely use computer-based tools, most often C.T. and M.R.I. scans of living patients. Some programs take advantage of the National Library of Medicine's Visible Human Project, which provides radiologic scans and actual digitalized photographs of cross sections of a male and female cadaver.
Computer-generated models — like one program that gives the viewer the illusion of flying through the nooks and crannies of a human skull — can clarify tiny, convoluted anatomical structures in a way that actual preserved specimens cannot.
A handful of schools now pare down anatomy courses by sparing students all hands-on contact with a cadaver. At the University of California at San Francisco, for instance, students learn anatomy by inspecting important structures in cadavers that have already been dissected by an instructor.
Studies have shown that students who learn anatomy from professionally prepared dissections, called prosections, perform about as well on standardized tests as those who do the dissection themselves. But anatomists bristle at any suggestion that either prosections or computer models will make them obsolete.
"It is very definitely not a trend," Dr. Dalley said.
Dr. Todd Olson, a professor of anatomy at Albert Einstein College of Medicine in the Bronx, noted, "There are some excellent computer-based resources, but they are not a replacement for the cadaver."
Dr. Carol Scott-Conner, a professor of surgery at the University of Iowa who is president of the American Association of Clinical Anatomists, said she was not sure "that every medical student needs an intensive anatomy course."
"But everybody needs to learn anatomy," she said, adding that actively participating in a dissection is a better way to learn than looking at an exhibit or a computer screen.
Even when the details of anatomy and the Latin names fade from a doctor's memory, memories of the experience remain vivid, Dr. Scott-Conner said.
Further, drawings and models ignore the huge variability in human anatomy, in which duplicated, misshapen or aberrant structures are common. Students who spend time searching for an important nerve or a blood vessel that surfaces nowhere near where it is supposed to be learn a hands-on lesson about the huge range of normal in medicine.
Anatomists also emphasize that working with a cadaver elicits a sense of reverence that pictures and models do not.
Medical attitudes toward human specimens have varied over the years. Apocryphal stories from the 19th and early 20th centuries describe medical students jumping rope with the intestines of cadavers, and playing lewd practical jokes with cadavers' genitalia.
As recently as 30 years ago, medical students who expressed any fear or squeamishness about human dissection were often told they were "weak" and in the wrong field, Dr. Olson of Einstein said.
Now, however, schools uniformly encourage students to work through their emotions, he said, and also make sure they understand the gravity of the proceedings.
"Students are informed at the beginning of the course that gross anatomy is a solemn endeavor and disrespect will not be tolerated," said Dr. Charles Maier, who directs the anatomy course at Case Western Reserve University Medical School.
Dr. Maier, like many other course directors, tells students the cadavers are their "first patients," to be treated with all the respect that living patients would command.
Funeral services held at the end of anatomy courses emphasize this point.
"Many if not most schools have memorial services of one sort or another" Dr. Maier said.
The nondenominational service at Case is held at a local cemetery and is similar to a standard graveside ceremony. Family members of the deceased are invited, and afterward, they mingle with the dozens of students who attend. Dr. Maier said he routinely received letters of thanks from families after the events.
Medical students at the State University of New York at Stonybrook keep a two-month diary of their time in the dissection laboratory as a part of a course on medicine in society.
"Some say they're not affected by it and it hasn't changed them at all," said Dr. Jack Coulehan, a professor of preventive medicine there, but a majority record a cascade of emotions, which the class then discusses.
At the Yale School of Medicine, practicing doctors periodically visit the first-year anatomy course to describe some of their dying patients to the students and to talk about the doctor's role in dealing with terminal illness and death.
"In medicine now there's a big emphasis on teaching students professionalism," said Dr. Lawrence J. Rizzolo, the director of the Yale course. "In anatomy we begin the discussion — how the student will function as a professional, learning how to react to an uncomfortable situation, facing death and dying. We get them in touch with their feelings."
When the anatomy course ends, the Yale students thank their donors, as they call the cadavers, in a ceremony that includes original poems and musical compositions. Every first-year student attends, Dr. Rizzolo said, and the service has come to celebrate not only the rite of passage of the anatomy course but also the students' immersion in medicine.
"Studying medicine is a privilege, and the service paid homage to that," said Zach Goldberger, a Yale student who performed an original piano elegy at the ceremony his class held three years ago.
Two years ago, Yale students created a colorful quilt to commemorate the anatomy course, with panels dedicated to each cadaver in their course.
Asked to contemplate medical education without cadaver dissection, Yale students were unenthusiastic.
"It's not just about the information," said Dagan Coppock, a fourth-year medical student. "It's about the process."
Mr. Coppock called the anatomy class "a powerful, sacred experience."
Without dissection, students would never get to see "how it all fits together," said his classmate Kavita Mariwalla.
"It gives you a real appreciation for the beauty of the human body," she said. "It's amazing. You are so thankful for it. It made me stand in awe."
"In medicine now there's a big emphasis on teaching students professionalism," said Dr. Lawrence J. Rizzolo, the director of the Yale course.
I guess this means don't leave instruments and sponges in your patient and don't cut off the wrong limb.
"In anatomy we begin the discussion — how the student will function as a professional, learning how to react to an uncomfortable situation, facing death and dying. We get them in touch with their feelings."
When the anatomy course ends, the Yale students thank their donors, as they call the cadavers, in a ceremony that includes original poems and musical compositions. Every first-year student attends, Dr. Rizzolo said, and the service has come to celebrate not only the rite of passage of the anatomy course but also the students' immersion in medicine.
"Studying medicine is a privilege, and the service paid homage to that," said Zach Goldberger, a Yale student who performed an original piano elegy at the ceremony his class held three years ago.
Two years ago, Yale students created a colorful quilt to commemorate the anatomy course, with panels dedicated to each cadaver in their course.
Poems, elegies and quilts for your cadaver, sounds a little strange to me.
The macabre circumstance brings out the "black humor"--a defense mechanism that helps a lot of med pros cope--as long as they don't try to share the humor with the public, who would naturally regard it as insensitive.
I have observed that cadavers are often named by their prosection students.
Mostly there's the dire warning by the pathologists/morticians--"Don't play with the corpses. You'll get arrested and expelled." Consider the temptation, come Halloween....
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