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Quidne Mortui Vivos Docent? The Evolving Purpose of Human Dissection in Medical Education

Dyer, George S. M.; Thorndike, Mary E. L.

INSTITUTIONAL ISSUES: ARTICLES
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The dissection experience has evolved over the past 500 years, following broader cutural trends in science and medicine. Through this time each period has recruited human gross anatomic dissection for characteristic purposes. Key variables have been: (1) the motivating philosophies of medicine and science, (2) how well clinical medicine and basic science have been integrated by anatomy, and (3) how explicity thoughts or feelings about death and dying have been addressed in the context of anatomy. The authors are especially interested in the third variable, and suggest that although anatomy is scientifically in decline, dissection is currently enjoying a revival as a vehicle for teaching humanist values in medical school.

Changes in the culture of medicine have carried anatomy from a research science, to a training tool, nearly to a hazing ritual, to a vehicle for ethical and moral education. Physicians, scientists, and medical students, as well as observers such as sociologists and writers, have been only intermittently aware of these cultural shifts. Yet anatomic dissection has been remarkably presistent as a feature of medical education—indeed it stands out as the most universal and universally recognizable step in becoming a doctor. This paper attempts to explore and interpret in detail the history of anatomy education, drawing on both subjective commentary and objective data from each period.

Mr. Dyer and Ms. Thorndike are third-year medical students, Harvard Medical School, Boston, Massachusetts. The authors are listed alphabetically.

Correspondence and requests for reprints should be addressed to Mr. Dyer, Harvard Medical School, Division of Medical Ethics, Department of Social Medicine, 641 Huntington Avenue, Boston, MA 02114; e-mail: 〈george_dyer@student.hms.harvard.edu〉.

Qudine mortui vivos docent: What do the dead teach the living? Although medical anatomists have always focused mainly on teaching the facts of the body's organization, the dissection experience has evolved over the past 500 years, following broader cultural trends in science and medicine. We have traced a pathway of change in the role of anatomic dissection that parallels broader changes in medicine and society. Through this time each period has recruited human gross anatomic dissection for characteristic purposes. Key variables have been: (1) the motivating philosophies of medicine and science, (2) how well clinical medicine and basic science have been integrated by anatomy, and (3) how explicitly thoughts or feelings about death and dying have been addressed in the context of anatomy. We are especially interested in the third variable, and we suggest that although anatomy is scientifically in decline, dissection is currently enjoying a revival as a vehicle for teaching humanistic values in medical school.

Changes in the culture of medicine have carried anatomy from a research science, to a training tool, nearly to a hazing ritual, to a vehicle for ethical and moral education. Physicians, scientists, and medical students, as well as observers such as sociologists and writers, have been only intermitently aware of these cultural shifts. Yet anatomic dissection has been a remarkably persistent feature of medical education—indeed it stands out as the most universal and universally recognizable step in becoming a doctor. No doubt, much of the explanation for this persistence is that performing dissection is an excellent way to learn anatomy, which remains central to the partice of medicine. However, dissection is also a multi-model experience, involving unique smells, sounds, and textures as well as intellectual content. Thus, although perhaps the information content of the anatomy lab could come from elsewhere, its social and psychological value can derive only from the actual experience of dissection. In this article, we attempt to explore and interpret the history of anatomy education from the time of Galen to the present.

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HUMAN ANATOMY AS RECEIVED WISDOM: THE DOMINATION OF GALEN

More than perhaps any other individual, the second-century Greek physician Galen was a dominant figure in the history of anatomy. Latin versions of his texts were the standards for anatomy in the Western world for more than 1,000 years. And although Galen himself was a proponent of direct empirical observation and made numerous discoveries in anatomy and physiology through direct experimentation on animal subjects, his texts were to become a substitute for such direct observation.1

Throughout the middle ages, professors of anatomy did not actually take part in dissection but rather lectured verbatim from Galenic texts. To study anatomy actually meant studying Galen. Dissections were performed on executed criminals once or twice a year. An illustration from Johannes de Katham's 1491 Fasciculus Medicinae, as described by Sherwin B. Nuland in Doctors, illustrates the teaching of anatomy at this time:

The professor sits perched high on what is quite literally his chair, droning along in his recitation of the Latin Galenic text while an ignorant barber-surgeon dissects the cadaver below and a barely better-schooled demonstrator shows the body parts to the only mildly interested students…. Since the professor never descended from his magisterial throne to actually look at the structures being displayed, and neither the surgeon nor the demonstrator really knew what he was doing, the several days devoted to the exercise each year were little more than a walk-through to satisfy a curricular requirement whose advantages were more theoretical than real.1

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SCIENCE AND HUMANISM

All this began to change with the publication in 1543 of Andreas Vesalius' masterpiece, De Humani Corporis Fabrica. Vesalius, a young physician and professor at the University of Padua, was a master dissector. Through skilled dissection and direct observation of anatomic structures, he showed where Galen was wrong, and more important, showed the importance of seeing for oneself. Galen, Vesalius concluded, had learned most of his anatomy from animals, while Vesalius insisted on the human body itself as the source of anatomic information. The text of the Fabrica was accompanied by exceptionally fine woodcuts depicting human bodies at various stages of dissection.

Vesalius embodied the guiding intellectual values of the Renaissance, a time of increased interest in both science and humanism. The human body became an object of study, useful in revealing interwoven truths about mankind, nature, and the divine. Artists such as Leonardo da Vinci and Michelangelo were interested in anatomy and themselves dissected bodies in order to learn how to portray the human form. Jan Stephan van Calcar, the artist who worked with Vesalius on the Fabrica, was a pupil of Titian. Anatomy at this time thus represented a complex interweaving of art, science, medicine, and humanism. Joseph Lella and Dorothy Pawluch, writing about this era, argue that “[e]xplicit, shared and sometimes public answers to ultimate questions about life and death were more fully integrated into the teaching of human anatomy and dissection until well into the 19th century.”2

The artistic tone of the engravings and drawings made by anatomists in this period demonstrates a spiritual and humanist subtext. A recurrent theme is that through dissection it was possible to learn more about God, and through aesthetic display it was possible to demonstrate something about the human condition. For example, the corpses in the engravings of Vesalius' De Humani Corporis Fabrica were placed in classical poses, and set against recognizable scenery in classical Rome. In some of Vesalius' illustrations partially dissected specimens are depicted in life-like, erect poses with semidetached muscles seeming to drip off of their outstretched limbs. (See Figure 1.) Thus the visual dissonance of dead and dismembered human figures carrying out the activities of life invites the reader to ponder what separates life from lifelessness. Vesalius' text also includes meditative references to life and the human condition.2,3

Figure 1

Figure 1

An even more striking example of this aesthetic can be seen in anatomic displays made by Frederik Ruysch, a Dutch professor of anatomy who lived from 1638 to 1731. A woodcut of one particularly bizarre museum display, prepared by Ruysch in 1703, is shown in Figure 2.

Figure 2

Figure 2

Ruysch has clearly invested this specimen with profound emotional or spiritual meaning. Although it defies complete interpretation, or perhaps even description, F. J. Cole's 1944 History of Comparative Anatomy makes a courageous attempt:

A [child's] skeleton balances an injected spermatic plexus in one hand and a coil of viscera in the other; minatory assortments of calculi of all sizes and shapes occupy the foreground; in the rear a variety of injected vessels backed by an inflated and injected tunica vaginalis combine to form a grotesque arboreal perspective; another skeleton in extremis is grasping a specimen of that emblem of insect mortality, the may-fly, and a third is performing a composition “expressing the sorrows of mankind” on a violin symbolized by a bundle of injected arteries and a fragment of necrotic femur. Of those vast philosophic conceptions which [animate this specimen], no suggestion can be traced.4

While it is hard to argue with Cole that the details of Ruysch's spellbinding opus are difficult to fathom, it is easy to conclude at least that anatomy was serving a humanist purpose, however peculiar it was in this case.

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THE SACK-EM-UP MEN: SCIENTIFIC ANATOMY AND GRAVE ROBBING

The teaching of gross anatomy began to change in character with the rise of effective surgical therapy for disease. The introduction of anesthesia and sterile technique allowed surgeons to enter the abdomen and other difficult areas, and to work longer and achieve better postoperative results. With these increasingly good outcomes, surgical intervention grew explosively and became a dominant mode of medical therapy. As surgical science progressed, anatomy was taken from the realm of the artistic, humanist, and descriptive and became a practical skill many physicians needed every day. As a field of basic science, the rationalization of anatomic study echoed the broader rise of rational, experimental, and objective science as a whole. In anatomical depiction, the fanciful and deliberately disturbing gave way to the precise, and humanistic reflection on the meaning of death was largely drowned out for the next two centuries.

We have not found any primary source describing students' or instructors' emotions about dissection in this period, but several indicators suggest it was a relatively unreflective time. Medical students seem to have been motivated by the excitement of new scientific discoveries and the promise of applying those discoveries directly to the cutting edge of medicine.

One of the things that makes this period seem callous is that, because dissecting bodies was against the law, doctors and their students had to steal corpses from graves and dissect them rapidly and in secret. Many historical accounts describe how widespread this practice was, and chronicle periodic popular riots and uprisings against doctors and medical students.5–7 This image is even evident in the day's popular culture. In Mark Twain's Adventures of Tom Sawyer, one of Tom and Huck's adventures is set against the backdrop of accidently witnessing a grave-robbing gang led by a young doctor.8

To end the need for grave robbing, in 1825 the Harvard faculty and the Massachusetts Medical Society began lobbying for a law legalizing medical dissection. They also conducted a public relations campaign designed to rehabilitate the image of body-snatching medical students and to appeal to the public's interest in competent surgical practitioners. The Massachusetts Anatomy Act was passed in 1831 and amended in 1834, allowing unclaimed bodies to be given to medical schools. Similar acts were soon passed in Connecticut, New Hampshire, Michigan, and New York, although many were later repealed. By the 1860s, only Massachusetts and New York had anatomy statutes on the books. Even in those states with functional anatomy acts, extralegal procurement of cadavers was still common. As late as the 1890s, half of the cadavers used by Johns Hopkins were obtained outside legal channels, and gave robbing was practiced in Tennessee through the 1920s.9

A recurrent theme in historical studies of this period is that physicians were in a catch-22 situation. The public “demanded of practitioners of medicine and surgery a practical knowledge of the anatomic structure of the human body, while on the other hand, the forces of human prejudice, ignorance, superstition, and piety in the legislative halls united in a conspiracy to prevent medical students from acquiring such knowledge by failing to provide for the legal acquisition of cadavers.”6 While it is very likely this was so, the rudimentary state of surgical anesthesia suggests an additional dehumanizing force was at work.

Because the discipline of surgery developed before the widespread availability of effective anesthesia, surgeons had to be willing to inflict terrible pain on patients, and learned to distance themselves from their agony under the knife. Many surgeons of the time commented that because fast operations had better survival rates, a good surgeon was one who could proceed unflinchingly and rapidly despite a patient's agonized screams. However, Matthew Pernick, in The Calculus of Suffering in 19th Century Surgery, has argued that this learned insensitivity took on a more sadistic tone as American surgery developed its own “heroic” culture, which featured “bold, courageous” physicians battling disease with “unrestrained infliction of excruciating remedies.”10 Lella and Pawluch explicitly connected the practiced heartlessness of 19th-century medicine with a humanist vacuum in the methods and goals of human anatomic dissection at that time.2

As anatomic dissection by students gained legitimacy and became an important part of the medical curriculum, at least at elite schools, the focus was on clinical anatomy as related to surgery. Anatomy was usually taught by surgeons. However, there was substantial debate among those interested in medical education about the proper role of anatomy. Between 1880 and 1910, two schools of thought emerged. One camp argued for “practical, applied human anatomy.” Several other commentators echoed these concerns, calling for a focus on clinical anatomy, surgically oriented, and taught by MDs.9 The second camp was led by Franklin P. Mall, who was the first professor of anatomy at Johns Hopkins, appointed in 1893. Mall's vision was that anatomy should be a research-oriented science, taught as one part of training medical students in scientific thinking and method.

Mall instituted a number of wide-ranging reforms in the teaching of anatomy at Hopkins. At Mall's initiative, anatomy at Hopkins was the starting point of medical school, no lectures were held, and students worked independently in small groups with input from instructors as requested. Mall also believed that students would learn best under a block-type system, studying one subject at a time in depth. Mall and other reformers such as Charles Sedgwick Minot at Harvard worked to define anatomy as a science to be taught by researchers, rather than as a clinically-oriented discipline grounded in surgery.9

In their history of Harvard Medical School, Henry K. Beecher and Mark D. Altschule call the period from the 1880s to the turn of the century the “heyday” of gross anatomy. It was marked by substantial research in the field, and accompanied by “ever-increasing prestige in the office of demonstrator.”11 Corroborating evidence can be found in an 1874 annual review of the field of anatomic research, written by Thomas Dwight, MD, who later became chairman of Harvard's Department of Anatomy. His brief synopsis mainly describes papers about interesting anomalies discovered in recent dissections. It even appears that some fundamental features of normal human anatomy were still under research at the time, as his review describes a new paper about the nature of the circle of Willis.12

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DECLINE AND FALL OF A SCIENTIFIC EMPIRE

Even in the “heyday” of gross anatomy, however, hints of gross anatomy's eventual eclipse by histology and cell biology are discernible. As medical school reform proceeded in the period following Abraham Flexner's damning survey of American medical education,13 Mall's vision came to guide the teaching of anatomy at most medical schools. Anatomy departments were staffed with anatomists who were basic scientists studying everything from rats to cells. In fact, they were mostly studying rats and cells; under the anatomy-as-science paradigm, very little research was conducted in gross anatomy, the subject arguably most relevant to medical school courses. Scientific anatomy in the 20th century was microscopic anatomy (histology, cytology), or comparative and developmental anatomy (zoology, embryology).

The direct relevance of anatomic research to anatomy teaching was harder and harder to see. After all, students still needed to learn the names of all the structures that had been discovered thousands of years before. The microscopic, comparative, and developmental aspects of anatomy were increasingly considered to be disciplines in their own right. In the words of one commentator, scientific anatomy was beginning to be a “victim of its own success.”9

To show an example of this we have looked in detail at anatomy at Harvard Medical School. There, the decline of gross anatomy appears to have been all but complete by the 1920s. In the period from 1880 to 1920, the major innovation in the clinical curriculum at Harvard was to incorporate histology, and an increasing proportion of research in the Department of Anatomy was devoted to histology and embryology.

In their history of Harvard, Beecher and Altschule give three reasons for anatomy study's decline: (1) the scant likelihood of any new discoveries; (2) the evolution of surgery toward subspecialties, making full-body gross anatomy less necessary; and (3) the rise of histology and embryology as new areas of research. It appears that by this time the teaching of gross anatomy had been relegated almost entirely to clinicians, a sign of diminished scientific prestige.14

To the extent that anatomy remained part of Harvard's research program, it had switched its focus entirely to cellular and biochemical investigation. Evidently concerned about the department's future, two of its chairmen deliberately pushed it in this direction so it would attract talented investigators. Professor George Wislocki, chairman from 1931 to 1943, urged that developments in biochemistry and physical chemistry be used to “provide opportunities for a new approach to the study of cells and tissues.”14

Professor Don W. Fawcett, chairman beginning in 1959, moved the Department of Anatomy further in this direction by deploying it in the service of other fields, most notably neuroscience. The electron microscope was just beginning to be used as a tool in histology, and as an assistant professor Fawcett successfully secured funds for Harvard Medical Schools' first one. By the 1970s it appears that the research program of the anatomy department had become entirely the servant of other fields.14

These trends at Harvard were mirrored nationwide. In 1942, one analysis of papers published in anatomy showed that 8% were on topics in gross anatomy, 11% in endocrinology, 20% in histology, and 25% in embryology. The majority of study subjects were rodents (27%) or sub-mammalian species (21%) (Lassek, 1942, in Blake9). A later study showed that between 1956 and 1961, only 9% of published papers were in gross anatomy.9

By the 1960s and '70s, anatomy as construed by Mall and the scientific reformers of the turn of the century was in trouble. With exciting discoveries ranging from antibiotics to the structure of DNA, it was clear that the cell and molecule were the essential sites of biologic inquiry for the 20th century. Anatomic research might have been keeping pace with this, but anatomy teaching remained rooted in the unglamorous world of gross anatomy.

The annual report of Harvard's Department of Anatomy, 1961–1962, neatly encapsulates this. The staff at that time was about half MDs and the other half PhDs. About a fourth had clinical appointments through one of the Harvard-affiliated hospitals. Of the papers published by members of the department the previous year, all concerned microscopic structures, and many were tied directly to biochemical lines of inquiry. Most revealing is the baleful tone struck by George Erikson, the assistant professor in charge of the gross anatomy course for first-year medical students. His brief and seemingly hopeless report on the course bemoans the students' evident lack of interest in gross anatomy and their worsening grasp of the material, shown by declining scores on final examinations each year.14

Frederic Hafferty's study of medical students at an unnamed “highly selective” East Coast medical school in the mid-1970s lends further credence to this picture. At this school, anatomic dissection was not even a required part of the curriculum, and the majority of students declined even to attend the offered lab.15

Nationally, the relative decline of anatomy can be seen in the decreasing amounts of time allotted it in the medical school curriculum (see Figure 3). In 1902, a survey of the 41 medical schools that had four-year curricula showed an average of 549 curriculum hours spent on gross anatomy. By 1955, it was down to 330 hours.9 Today, a relatively thorough curriculum might dedicate 225 hours to gross anatomy (three hours of lecture and 12 hours of lab per week for a semester). At the briefest end of the spectrum, Harvard's New Pathway teaches all of anatomy and histology in only 180 hours of class time, including only 48 hours of gross anatomy lab.

Figure 3

Figure 3

Writing in 1977, Beecher and Altschule made the over-optimistic prediction that the Department of Anatomy would continue to evolve along with fields such as neuroscience, which began as offshoots of anatomy but subsequently became its patrons. Instead, in 1994 Harvard Medical School closed its Department of Anatomy. Faculty were moved to the Department of Cell Biology and other departments.

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ANATOMY AND THE SOCIALIZATION OF MEDICAL STUDENTS IN THE 20TH CENTURY

The fortunes of anatomy departments may have risen and fallen with changes in the research environment, but there was at least consensus about what anatomy was supposed to be teaching. Medical students were supposed to learn anatomy: the names, relations, courses, origins, and insertions of the bones, muscles, vessels, nerves, and organs of the human body. There was no para-curriculum, no sense that any further educational goals were served by requiring students to dissect a cadaver. However, outside observers of medical education often identified additional, less explicit functions of dissection. Medical sociologists conducted studies of medical education, and looked carefully at students' responses to dissection in an attempt to understand how dissection might function in socialization. Three sociological accounts, by Howard Becker et al., by Renee Fox, and by Frederick Hafferty, provide interesting insight into this process.

Howard Becker, Blanche Geer, Everett Hughes, and Anselm Strauss studied students at the University of Kansas Medical School in the 1950s. They were particularly curious about how students would respond to the presumably traumatic experience of anatomy lab. In preparation for their study, team members read popular fiction about medical training, which led them to expect hardened, cynical medical students tossing parts of the cadavers around the lab while making obscene jokes.

But in their findings, Becker and colleagues reported that they saw nothing of the kind, although they freely admitted that they “made no attempt to get at [students'] inner experience.”7 They concluded that first-year medical students were overwhelmingly concerned with the volume of work demanded of them, and that this overrode any feelings about the nature of that work.

Medical sociologist Renee Fox spent four years as a participant—observer at Cornell Medical School in the 1950s, and saw something rather different. Fox described students as naturally distressed by dissecting a human subject, and as learning to manage that distress by repressing their emotions and the developing a “scientific” attitude. Fox explicitly addressed the idea that dissection functions to teach more than anatomic content: anatomy lab is part of students' “attitude-learning,” preparing them for practice as physicians. The most important attitude learned through dissection is “detached concern,” a particular balance of caring and detachment deemed essential to medical practice. She quoted a student in her study as follows: “You have to overcome some of your emotion, and learn to look at things objectively and scientifically. But you also have to preserve a certain amount of feeling. Because if you're a cold fish, you won't be good with patients. So you worry about becoming over-callous to things you were once sensitive to.”16

Twenty years later, sociologist Frederick Hafferty spent a year as a participant—observer among first-year medical students in an unnamed private, “highly selective” East Coast medical school. In contrast with Becker, Hafferty indeed attempted to get at his subjects' inner experience with indepth interviews and observation. His insightful analysis reveals much about medical students' experience of human dissection and its role in medical education.17

Like Fox, Hafferty argued that there is an important socializing function served by dissection. However, he worried that he saw more detachment and less concern. Hafferty painted a bleak yet persuasive picture of anatomy lab as a test of student's toughness, a forum for learning to “handle” disturbing experiences without revealing weakness or emotion. Hafferty found many of his informants to be privately reflective and often quite distressed by dissection but publicly adherent to a norm of silence about emotional content. In this context, “the dissection of a human cadaver represents a test of one's emotional competence to become a physician.”17 Dissecting is an “emotional Rubicon” separating the successful from the weak.

Like many others before him, Hafferty had heard tales of students' throwing body parts and sexual desecration in the lab, and like others he failed to observe such behavior. However, he argued that such “cadaver stories” are seemingly universal among medical students and in fact serve an important purpose as mediators of the student experience of dissection. These stories are usually told as fact, with a “reality anchor” asserting veracity: “My friend at Columbia told me” or “When my dad was in med school.” They usually tell of medical students perpetrating outrageous pranks on each other or on gullible, non-medical “outsiders”: handing a toll-taker a severed hand, putting a severed penis in another cadaver's vagina, and the like.

Do such things actually happen? No, probably not. Hafferty argued that although it is unlikely that most students would give a toll-taker a severed hand, medical students like to think of themselves as the kind of people who could. He claimed that medical students find these stories hilarious, and use them as a way of symbolically defining the initiated (cool, detached, in control, usually men) as opposed to the uninitiated (weak, emotional, vulnerable, usually women).

Hafferty identified a division among his informants that separated them into two camps: those who conceptualized their cadavers as primarily biologic specimens (41% of the class) and those who saw them primarily as formerly living human beings (38% of the class).17 This division into categories, which we will call Group I and Group II, turned out to have important predictive value for how students would respond to the experience of dissection.

Group I students, who identified their cadavers as biologic specimens, tended to say things like “To me the cadaver is a complete nonperson. You really don't think of it as being your body or somebody else's. It's just like a rubber model. When somebody says that the cadaver died of something, it sounds really strange. You don't think of it that way. I think it's pretty stupid to be squeamish with cadavers.”17 Group I students tended to refer to norms of scientific detachment and control of emotions. They were openly critical of Group II students, whom they perceived as “over-involved,” emotional, and weak. Group I students were more likely to be men, more likely to name their cadavers, and less likely to consider donating their own bodies for dissection after death.

Group II students, for their part, were equally critical of Group I:

One of the basic premises I have about lab is that you should have a reaction to it—the thoughts, the sights, the smells—because this is a dead person and you're going to be dead someday, too, and this is an inescapable association. There are people working in lab with me who never express their emotions. If they don't have that emotional sensitivity now, they'll be doing the same thing later on. There are going to be a lot of patients you are going to have to care for that will be physically, or whatever, unable to react to you, just like a cadaver, and you've got to be able to make yourself aware of the patient's feelings, his pain or discomfort, and acknowledge this as part of your work, something you must have if you're going to be a good doctor.17

These students tended to be more reflective and to articulate adherence to humanistic values and the importance of emotion in the doctor-patient relationship. They frequently voiced fears of becoming “hardened” by medical education, and tended to have explicit awareness of the socializing functions of experiences such as the anatomy lab. Group II students were more likely to be women, less likely to name their cadavers, and more likely to consider donating their own bodies for dissection after death.

Another revealing area of analysis was lab attendance. At this particular medical school, lab attendance was not required, and only a minority of students consistently attended. The three most commonly given reasons for non-attendance were quality of cadavers, quality of instructors, and lab-mate relations. However, upon more careful interviewing, Hafferty classified 31% of those who actually dropped out as doing so for emotional reasons. Only 27% of the class were consistent attenders. What this group seemed to have in common was a vision of the anatomy lab as an opportunity for personal growth: “For me, going to lab is not really for the learning, it's for the personal reasons, getting over things you find repulsive, but you want to get over it so that you can work and deal with your patients as people and not let the repulsiveness of their conditions get to you. This is the purpose of lab for me.”17 Interestingly, either Group I or Group II students could take this approach, depending on the personal growth goals they endorsed. Lab could help you learn to control your emotions or to be more in touch with them, as you wished.

Michael Crichton, Harvard Medical School's most famous non-practicing graduate of this period, includes a brief description of gross anatomy lab in Travels, his midlife autobiography. It contains some cadaver stories, evidently intended to call attention to his own status as a person initiated in the medical community. He also must have read Renee Fox, either then or since, because he self-consciously describes the experience of anatomy as a place to learn “detached concern.” His approach seems to have been very detached, though, and the disturbing first sentence of the book seems designed to shock the reader with its grittiness, and his medical student's superhumanly thick skin. “It is not easy to cut through a human head with a hacksaw,” the passage begins, innocuously enough. But then Crichton reveals his joke: his difficulty is purely technical, not emotional. The passage continues: “The blade kept snagging the skin, and slipping off the smooth bone of the forehead. If I made a mistake, I slid to one side or the other, and I would not saw precisely down the center of the nose, the mouth, the chin, the throat. It required tremendous concentration.” Crichton tries to re-humanize this vision by concluding the paragraph, “I could not really acknowledge what I was doing, because it was so horrible,” but the portrait he goes on to paint of his experience makes it clear he really did see it as a toughening-up.18

The illustration in Figure 4 is the aesthetic embodiment of this dehumanizing detachment. It is a picture by Frank Netter from his Atlas of Human Anatomy, the standard for modern anatomy students.19 It is also a picture of Frank Netter, as he would look if his face were sliced off in a coronal plane just at the paranasal sinuses. A few moments' careful inspection of the “Netter in his studio” photograph in the front of the Atlas' second edition, and then of Plate 20, where Netter shows a middle-aged man's face covered with skin tumors, makes it clear Netter has used himself as the model for both of these disturbing images. What on earth for? Why would a person choose to depict himself as a cadaver, disfigured by skin tumors or with his face sliced away? Painters from Rembrandt to Norman Rockwell have inserted self-portraits into their work, often in an ironic way. Perhaps Netter was self-consciously making a joking reference to himself as cadaver artist, or perhaps he simply found himself a convenient model. But either way, these bizarre illustrations are the natural extension of the trends we have outlined—they are the ultimate cadaver story. Frank Netter evidently achieved such detachment from the emotional strain of the anatomy lab that he was able to dissect himself.

Figure 4

Figure 4

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FROM “CADAVER” TO “DONOR”: THE RISE OF THE PARA-CURRICULUM

As anatomy departments struggled to define their mission and identity in the midst of the molecular biology revolution, forces were at work that offered a possible area of growth and change for anatomy teaching. With the publication of Elizabeth Kubler-Ross's highly influential On Death and Dying, there was a widespread surge of interest in issues of death. The hospice movement articulated a vision of the “good death,” calling on the medical profession to be partners in the quest for humane and meaningful approaches to dying and end-of-life care.

It was only a matter of time before people began to apply some of these ideas to what went on in the anatomy lab. Hafferty's study, for instance, was framed explicitly in terms of understanding students' experiences in anatomy lab with reference to their feelings more generally about death and dying. Commentators on medical education began to make explicit calls for reform, suggesting that the experience of dissection was a rich opportunity for the exploration of feelings.20–22

At the same time, a number of studies made it clear that students were in fact experiencing a tremendous range of emotions in anatomy lab,19,23,24 including fear, horror, guilt, wonder, gratitude, and sadness. Cutting up a human body is a fundamentally disorienting thing to do. Byron Good has written persuasively about the way in which such experiences contribute to medical students' learning to see the world differently.24 Medical students are profoundly in transition, moving from being “regular people” to being doctors. The ritual, initiatory aspects of cadaver dissection are clearly relevant here. Medical students abandon their old identities at the door of the anatomy lab as they change into scrubs, take up a scalpel, and begin to cut.

Students have recently become more articulate about many of these feelings. Hafferty in the mid-1970s reported a public norm of silence about the emotional aspects of dissection, even though approximately half his sample privately revealed substantial emotional upheaval. However, in June Penney's study a few years later, the majority of students reported having discussed their feelings about dissection with others.25 Today, our experience suggests that there is in fact a normative expectation on the part of medical students that discussion of feelings is healthy and necessary. In our anatomy course, some students felt distress at not being disturbed by dissection, and reported a sense of pressure to experience dissection as an emotional event rather than as simply an intellectual one. In short, the norms of Hafferty's Group II have prevailed.

Today at Harvard Medical School, students still tell cadaver stories. However, we submit that the purpose of these stories has changed. Rather than demonstrating one's toughness and insider status, cadaver stories now serve to illustrate one's sensitivity and enlightenment. The stories are invariably told as examples of the kinds of awful things done in anatomy lab in the “bad old days,” or at other, “less enlightened” schools. We, the teller implies, would never do such things.

How did we get here? Have medical schools acted on the calls for reform and attempted to use students' emotional experiences as a springboard for learning about death, compassion, and the doctor-patient relationship?

Yes and no. We have recently completed a survey-based assessment of emotional teaching in anatomy courses. We surveyed the anatomy course directors, or the chairs of the departments of anatomy, at all the MD-granting medical schools in the United States, as listed by the Association of American Medical Colleges. We received responses from 54 schools. We asked (1) whether their curriculum addressed the emotional content of doing human dissection, (2) in what way, and (3) what the impetus had been for adding this component. Our preliminary analysis shows that although many of the respondants' programs (44/54) included elements the instructors described as addressing the emotional content of anatomy, few (7/54) had formal curricula for this.

Students' attention to the emotional aspects of dissection was strongly supported by at least some anatomy faculty. Dan Goodenough, one of the co-directors of the Harvard Medical School New Pathway block that includes gross anatomy, explained what he believes gross anatomy has the potential to teach.26 Goodenough is drawn to the power of the first few moments in the gross anatomy lab, pointing out that it is most students' first encounter with a dead human being. Furthermore, all beginning dissectors realize they are about to violate many basic social taboos: naked cadavers are viewed in mixed company and then methodically cut apart—an activity outside any other normal human experience. Goodenough believes the starkness of this moment makes students very “open” emotionally, creating a brief, golden opportunity to learn to combine detached concern, a necessary self-protection tool, with genuine empathy in a way that will best serve patients over a doctor's career.

The University of Massachusetts Medical School is in the vanguard for explicitly incorporating emotional lessons into its learning objectives for gross anatomy. In a required course called “On Dissection, Dying and Death,” designed and taught by Sandra Bertman, PhD, and Sandy Marks, DMD, PhD, students are asked to confront and develop their attitudes toward death and dying, and also to discuss them with each other and with their instructors.21

One aspect is an assignment students complete even before coming to medical school for the fall of their first year. They are asked make a drawing or collage to express their feelings about death and dissection and also to compose a short paragraph explaining their drawing. These are presented near the end of the course as a slide-show montage, so each student is reminded of what he or she thought about anatomic dissection before starting medical school, and also gets to see how classmates responded to the same assignment. See Figures 5 and 6.

Figure 5

Figure 5

Figure 6

Figure 6

Another example of a direct curricular approach to emotional and social issues in anatomy comes from the State University of New York at Stony Brook. First-year students here write a paper about the dissection experience as part of the Medicine in Contemporary Society course. The students are asked to “analyze your experience with the cadaver (e.g., how the “relationship” has affected you, what you have learned about yourself, what you have learned about other people). Try to identify, articulate, and reflect upon your own emotions and responses.” This is about as far as imaginable from Hafferty's observed norm of silence.

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CLOSING QUESTIONS AND REFLECTIONS

Some practical questions remain. For one thing, since a humanistic goal restores the humanity to cadavers, it is interesting to ask why people donate their bodies for anatomic dissection. A partial answer to this and a related question—what do donors know about what will happen to them—can be found in Anatomical Gift: Whole Body Donation Guide.27 This book describes itself as “a self-help guide for learning how to and where to donate your whole body to medical science from 115 medical programs in the United States.” Its stated purpose is to provide practical information to people who may be considering donating their bodies after death.

The book suggests two basic motivations for donating: to satisfy a personal commitment to advancing medical science and education, and to reduce the financial burden of final disposition after death. Interestingly, its (one-paragraph) case for the educational value of donated bodies rests entirely on the importance of anatomy as a foundation for medical practice, especially in surgical specialties. No mention is made of how a donor's future dissectors might think or feel about dissection, or that those feelings might serve an educational purpose. It also explicitly addresses the rumors of disrespectful treatment of cadavers, which the author must have thought might pose a potential obstacle to donation. Rather than dismissing them outright as fabrications, though, the author suggests they were part of a bygone era. If the new norms we predict in this paper take hold, it will be interesting to see how the expectations of donors catch up to the new educational goals of dissection.

Another question is who will teach anatomy in the future? We have predicted a humanistic resurgence of the discipline, but at the same time we see the continued erosion of its scientific prestige as inevitable. No gross anatomic structures remain to be discovered, and an inviolable law of academia condemns any field that stagnates for too long. This is reflected in a trend toward closing medical school departments of anatomy. At many schools, more anatomists retire than new ones are trained each year. All the anatomy instructors we spoke to in preparing this paper told us that they are concerned that no one will replace them. This presents a problem, since few believe the time has come for humanist goals to supplant practical ones entirely. For medical students to get in touch with their feelings is important, but as one instructor we interviewed put it, “Someone still has to know how to find the structures and show them to you.”28 It will be fascinating over the next ten years to observe how medical schools integrate the practical and humanist goals of anatomic dissection.

And finally, if indeed the changes we suggest are spreading throughout medical education, an important question remains unanswered: why? If the role of anatomy in medical education is changing, why, and why now? We have argued that as anatomy's scientific standing has diminished, its humanistic standing has grown. Have anatomy programs and anatomy teachers grasped at the humanities as a way to breathe life into programs that are dwindling in importance?

Probably not. Preliminary data from our survey indicate that most programs were initiated out of concern over students' emotional responses to dissection. Of the 23 respondents who answered at any length our question about the impetus for developing a program, 10 (43%) cited specific student request or student initiation. The remaining 13 (57%) said that their programs were started by faculty, either out of concern for student responses to dissection, out of concern over ethical issues in dissection, or both. The comments of Linda Hazlett, department chair at Wayne State School of Medicine, are typical: “The impetus was to develop a sense of respect for the donated body, and to deal with an emotional situation which was overwhelming for some.”

Most programs seem to have evolved from a growing understanding on the part of both students and faculty that dissection is potentially an emotionally difficult experience, and from a sincere desire to make the experience less problematic, more rewarding, and more intellectually useful for the students. As humanistic course content has grown, it has not been at the expense of the traditional course content but rather as a supplement to it.

This increasingly explicit attention to students' emotional experiences seems to be part of a number of larger trends in medical education, and higher education in general, in the last 30 years. Since the 1960s and 1970s, when students were sitting in, striking, and taking over campus buildings while demanding curricular and policy changes, the idea that students have a right to shape their own education has become deeply ingrained in the American university. Students expect their schools and professors to be supportive and responsive to student concerns.

A related trend is the increasing emphasis on “humanizing” medical education in general, which has been driven by fears that doctors are unfeeling technicians unskilled in basic human interactions. Most medical schools today include courses aimed at exploring the doctor-patient relationship, medical ethics, and understanding the larger social context of health and illness. It makes sense that eventually these trends would catch up to the anatomy lab, which has always been a highly charged and symbolically powerful part of medical education.

Yet another trend contributing to the changes in anatomy education is the increasing attention to the donor as a human being. Cadavers were originally stolen property, furtively dissected under cover of darkness and quickly abandoned. Once anatomy laws allowed for the use of unclaimed bodies, cadavers were less illicit but still in the category of found objects, unclaimed, somehow less than human. Today, donor programs emphasize the consent of the donor, and indeed frame the exchange as a gift given for altruistic reasons. This perhaps more than any other change gives the cadaver in today's laboratory a fully human face—and so the right to rituals of respect like the memorial services carried out at the majority of schools whose representatives responded to our survey.

If the changes in anatomy teaching are driven by these larger trends, it is interesting to look at how the changes have occurred. Are teachers of anatomy themselves initiating these programs or are they being dragged along by social forces originating outside the lab itself? Although our data indicate that the majority of programs are faculty-initiated, it is interesting to note that not all of the initiating faculty are anatomists. Two of the largest and most comprehensive programs, at the University of Chicago and at the State University of New York at Stony Brook, were started outside the departments of anatomy, by the departments of medical ethics and preventive medicine, respectively. Rather than anatomists' seeking to expand the importance of their courses through other disciplines, the other disciplines may be seizing on anatomy as an ideal site for expanding their own pieces of the curricular pie.

And the resulting coexistence is not always peaceful. One anatomy teacher who answered our survey reported a conflicted relationship between competing goals. He described how a newly-hired ethicist had created a course for medical students about the emotional impact of dissection that was run from outside the anatomy department. The course was extremely disruptive—it made some students too upset to continue with the dissection syllabus. This respondent was relieved when after a few unpleasant years the ethicist moved to another university, and he was able to resume dealing with the emotional impact of dissection on his students in his informal, time-tested way.

At this moment in history a confluence of forces seems to be changing the way medical education approaches the emotional content of gross anatomy. In part it is the evolution of the variables we outlined in our introduction: (1) contemporary philosophies of science and medicine have encouraged explicit consideration of ethical and moral themes even in very technical fields, and (2) anatomy is now devoted almost entirely to preparing students for clinical practice, rather than existing as a distinct field of science. Larger social changes in higher education and in American cultural views of death and dying have also contributed. But clearly more is going on. These are quite subtle shifts the philosophy of dissection, but we believe very visible changes are under way in medical schools. We have hinted at some of the other factors that have allowed small changes in philosophy to be manifested so readily in medical curricula—students' growing insistence on designing their own learning, and anatomy's ready fit with the sweeping effort to humanize medicine. However, more research is necessary to fully explore these changes.

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