by Mary Roach
Bad enough that some ham-handed fop in a waistcoat and bowtie was up to his wrists in your urinary tract, but on top of that you had an audience—not just the young punters from the medical school but, judging from a description of another lithotomy at Guy’s Hospital in an 1829 Lancet, half the city: “Surgeons and surgeons’ friends,…French visitors, and interlopers filled the space around the table…. There was soon a general outcry throughout the gallery and upper rows—‘hat’s off,’ ‘down heads,’…was loudly vociferated from different parts of the theatre.”
The cabaret atmosphere of early medical instruction began centuries before, in the standing-room-only dissecting halls of the renowned Italian medical academies of Padua and Bologna. According to C. D. O’Malley’s biography of the great Renaissance anatomist Andreas Vesalius, one enthusiastic spectator at a crowded Vesalius dissection, bent on a better view, leaned too far out and tumbled from his bench to the dissecting platform below. “Because of his accidental fall…, the unfortunate Master Carlo is unable to attend and is not very well,” read the note proffered at the next lecture. Master Carlo, one can be sure, did not seek treatment at the place he went for lectures.
Without exception, the only people who checked themselves in at teaching hospitals were those too poor to pay for private surgery. In return for an operation that was as likely to kill them as make them better—bladder stone removal had a mortality rate of 50 percent—the poor basically donated themselves as living practice material. Not only were the surgeons unskilled, but many of the operations being done were purely experimental—no one really expected them to help. Wrote historian Ruth Richardson in Death, Dissection, and the Destitute, “The benefit [to the patient] was often incidental to the experiment.”
With the advent of anesthesia, patients were at least unconscious while the young resident tried his hand at a new procedure. But they probably didn’t give their permission for a trainee to take the helm. In the heady days before consent forms and drop-of-a-hat lawsuits, patients didn’t realize what they might be in for if they underwent surgery at a teaching hospital, and doctors took advantage of this fact. While a patient was under, a surgeon might invite a student to practice an appendectomy. Never mind that the patient didn’t have appendicitis. One of the more common transgressions was the gratuitous pelvic exam. A budding M.D.’s first Pap smear—the subject of significant anxiety and dread—was often administered to an unconscious female surgical patient. (Nowadays, enlightened medical schools will hire a “pelvic educator,” a sort of professional vagina who allows the students to practice on her and offers personalized feedback and is, in my book anyway, a nominee for sainthood.)
Gratuitous medical procedures happen far less than they used to, owing to the public’s growing awareness. “Patients are savvier these days, and the climate has changed a great deal,” Hugh Patterson, who runs the willed body program at the University of California, San Francisco, Medical School, told me. “Even at a teaching hospital, patients request that residents not do the surgery. They want to be assured the attending does the procedure. It makes training very difficult.”
Patterson would like to see specialized cadaver anatomy labs added to third-and fourth-year programs—instead of teaching anatomy only in the first year, “as one big bolus.” Already, he and his colleagues have added a focused dissection, similar to the facial anatomy lab I’m observing today, to the curricula of surgical subspecialties. They’ve also set up a series of sessions at the medical school morgue to teach emergency room procedures to third-year students. Before a cadaver is embalmed and delivered to the anatomy lab, it may pass an afternoon getting tracheal intubations and catheterizations. (Some schools use anesthetized dogs for this purpose.) Given the urgency and difficulty of certain ER procedures, it makes good sense to practice them first on the dead. In the past, this has been done in a less formal manner, on freshly dead hospital patients, without consent—a practice whose propriety is intermittently debated in hushed meetings of the American Medical Association. They should probably just ask for permission: According to one New England Journal of Medicine study on the subject, 73 percent of parents of newly dead children, when asked, gave consent to use their child’s body for teaching intubation skills.
I ask Marilena if she plans to donate her remains. I have always assumed that a sense of reciprocity prompts doctors to donate—repayment for the generosity of the people they dissected in medical school. Marilena, for one, isn’t going to. She cites a lack of respect. It surprises me to hear her say this. As far as I can tell, the heads are being treated with respect. I hear no joking or laughter or callous comments. If there can be a respectful way to “deglove” a face, if loosening the skin of someone’s forehead and flipping it back over his or her eyes can be a respectful act, then I think these people are managing it. It’s strictly business.
It turns out that what Marilena objected to was a couple of the surgeons’ taking photographs of their cadaver heads. When you take a photograph of a patient for a medical journal, she points out, you have the patient sign a release. The dead can’t refuse to sign releases, but that doesn’t mean they wouldn’t want to. This is why cadavers in photographs in pathology and forensics journals have black bars over their eyes, like women on the Dos and Don’ts pages of Glamour. You have to assume that people don’t want to be photographed dead and dismembered, any more than they want to be photographed naked in the shower or asleep on a plane with their mouth hanging open.
Most doctors aren’t worried about a lack of respect from other doctors. Most of the ones I’ve spoken to would worry, if anything, about a lack of respect from students in the first-year gross anatomy lab—my next stop.
The seminar is nearly over. The video monitors are blank and the surgeons are cleaning up and filing out into the hallway. Marilena replaces the white cloth on her cadaver’s face; about half the surgeons do this. She is conscientiously respectful. When I asked her why the eyes of the dead woman had no pupils, she did not answer, but reached up and closed the eyelids. As she slides back her chair, she looks down at the benapkined form and says, “May she rest in peace.” I hear it as “pieces,” but that’s just me.
2
CRIMES OF ANATOMY
Body snatching and other sordid tales from the dawn of human dissection
Enough years have passed since the use of Pachelbel’s Canon in a fabric softener commercial that the music again sounds pure and sweetly sad to me. It’s a good choice for a memorial service, a classic and effective choice, for the men and women gathered (here today) have fallen silent and somber with the music’s start.
Noticeably absent amid the flowers and candles is the casket displaying the deceased. This would have been logistically challenging, as all twenty-some corpses have been reduced to neatly sawed segments—hemisections of pelvis and bisected heads, the secret turnings of their sinus cavities revealed like Ant Farm tunnels. This is a memorial service for the unnamed cadavers of the University of California, San Francisco, Medical School Class of 2004 gross anatomy lab. An open-casket ceremony would not have been especially horrifying for the guests here today, for they have not only seen the deceased in their many and various pieces, but have handled them and are in fact the reason they have been dismembered. They are the anatomy lab students.
This is no token ceremony. It is a sincere and voluntarily attended event, lasting nearly three hours and featuring thirteen student tributes, including an a capella rendition of Green Day’s “Time of Your Life,” the reading of an uncharacteristically downbeat Beatrix Potter tale about a dying badger, and a folk ballad about a woman named Daisy who is reincarnated as a medical student whose gross anatomy cadaver turns out to be himself in a former life, i.e., Daisy. One young woman’s tribute describes unwrapping her cadaver’s hands and being brought up short by the realization that the nails were painted pink. “The pictures in the anatomy atlas did not show nail polish,” she wrote. “Did you choose the color?…Did you think that I would
see it?…I wanted to tell you about the inside of your hands…. I want you to know you are always there when I see patients. When I palpate an abdomen, yours are the organs I imagine. When I listen to a heart, I recall holding your heart.” It is one of the most touching pieces of writing I’ve ever heard. Others must feel the same; there isn’t an anhydrous lacrimal gland in the house.
Medical schools have gone out of their way in the past decade to foster a respectful attitude toward gross anatomy lab cadavers. UCSF is one of many medical schools that hold memorial services for willed bodies. Some also invite the cadavers’ families to attend. At UCSF, gross anatomy students must attend a pre-course workshop hosted by students from the prior year, who talk about what it was like to work with the dead and how it made them feel. The respect and gratitude message is liberally imparted. From what I’ve heard, it would be quite difficult, in good conscience, to attend one of these workshops and then proceed to stick a cigarette in your cadaver’s mouth or jump rope with his intestines.
Hugh Patterson, anatomy professor and director of the university’s willed body program, invited me to spend an afternoon at the gross anatomy lab, and I can tell you here and now that either the students were exceptionally well rehearsed for my visit or the program is working. With no prompting on my part, the students spoke of gratitude and preserving dignity, of having grown attached to their cadavers, of feeling bad about what they had to do to them. “I remember one of my teammates was just hacking him apart, digging something out,” one girl told me, “and I realized I was patting his arm, going, ‘It’s okay, it’s okay.’” I asked a student named Matthew whether he would miss his cadaver when the course ended, and he replied that it was actually sad when “just part of him left.” (Halfway through the course, the legs are removed and incinerated to reduce the students’ exposure to the chemical preservatives.)
Many of the students gave their cadavers names. “Not like Beef Jerky. Real names,” said one student. He introduced me to Ben the cadaver, who, despite having by then been reduced to a head, lungs, and arms, retained an air of purpose and dignity. When a student moved Ben’s arm, it was picked up, not grabbed, and set down gently, as if Ben were merely sleeping. Matthew went so far as to write to the willed body program office asking for biographical information about his cadaver. “I wanted to personalize it,” he told me.
No one made jokes the afternoon I was there, or anyway not at the corpses’ expense. One woman confessed that her group had passed comment on the “extremely large genitalia” of their cadaver. (What she perhaps didn’t realize is that the embalming fluid pumped into the veins expands the body’s erectile tissues, with the result that male anatomy lab cadavers may be markedly better endowed in death than they were in life.) Even then, reverence, not mockery, colored the remark.
As one former anatomy instructor said to me, “No one’s taking heads home in buckets anymore.”
To understand the cautious respect for the dead that pervades the modern anatomy lab, it helps to understand the extreme lack of it that pervades the field’s history. Few sciences are as rooted in shame, infamy, and bad PR as human anatomy.
The troubles began in Alexandrian Egypt, circa 300 B.C. King Ptolemy I was the first leader to deem it a-okay for medical types to cut open the dead for the purpose of figuring out how bodies work. In part this had to do with Egypt’s long tradition of mummification. Bodies are cut open and organs removed during the mummification process, so these were things the government and the populace were comfortable with. It also had to do with Ptolemy’s extracurricular fascination with dissection. Not only did the king issue a royal decree encouraging physicians to dissect executed criminals, but, come the day, he was over at the anatomy room with his knives and smock, slitting and probing alongside the pros.
Trouble’s name was Herophilus. Dubbed the Father of Anatomy, he was the first physician to dissect human bodies. While Herophilus was indeed a dedicated and tireless man of science, he seems to have lost his bearings somewhere along the way. Enthusiasm got the better of compassion and common sense, and the man took to dissecting live criminals. According to one of his accusers, Tertullian, Herophilus vivisected six hundred prisoners. To be fair, no eyewitness account or papyrus diary entries survive, and one wonders whether professional jealousy played a role. After all, no one was calling Tertullian the Father of Anatomy.
The tradition of using executed criminals for dissections persisted and hit its stride in eighteenth-and nineteenth-century Britain, when private anatomy schools for medical students began to flourish in the cities of England and Scotland. While the number of schools grew, the number of cadavers stayed roughly the same, and the anatomists faced a chronic shortage of material. Back then no one donated his body to science. The churchgoing masses believed in a literal, corporal rising from the grave, and dissection was thought of as pretty much spoiling your chances of resurrection: Who’s going to open the gates of heaven to some slob with his entrails all hanging out and dripping on the carpeting? From the sixteenth century up until the passage of the Anatomy Act, in 1836, the only cadavers legally available for dissection in Britain were those of executed murderers.
For this reason, anatomists came to occupy the same terrain, in the public’s mind, as executioners. Worse, even, for dissection was thought of, literally, as a punishment worse than death. Indeed, that—not the support and assistance of anatomists—was the authorities’ main intent in making the bodies available for dissection. With so many relatively minor offenses punishable by death, the legal bodies felt the need to tack on added horrors as deterrents against weightier crimes. If you stole a pig, you were hung. If you killed a man, you were hanged and then dissected. (In the freshly minted United States of America, the punishable-by-dissection category was extended to include duelists, the death sentence clearly not posing much of a deterrent to the type of fellow who agrees to settle his differences by the dueling pistol.)
Double sentencing wasn’t a new idea, but rather the latest variation on the theme. Before that, a murderer might be hanged and then drawn and quartered, wherein horses were tied to his limbs and spurred off in four directions, the resultant “quarters” being impaled on spikes and publicly displayed, as a colorful reminder to the citizenry of the ill-advisedness of crime. Dissection as a sentencing option for murderers was mandated, in 1752 Britain, as an alternative to postmortem gibbeting. Gibbeting—though it hits the ear like a word for happy playground chatter or perhaps, at worst, the cleaning of small game birds—is in fact a ghastly verb. To gibbet is to dip a corpse in tar and suspend it in a flat iron cage (the gibbet) in plain view of townsfolk while it rots and gets pecked apart by crows. A stroll through the square must have been a whole different plate of tamales back then.
In attempting to cope with the shortage of cadavers legally available for dissection, instructors at British and early American anatomy schools backed themselves into some unsavory corners. They became known as the kind of guys to whom you could take your son’s amputated leg and sell it for beer money (37½ cents, to be exact; it happened in Rochester, New York, in 1831). But students weren’t going to pay tuition to learn arm and leg anatomy; the schools had to find whole cadavers or risk losing their students to the anatomy schools of Paris, where the unclaimed corpses of the poor who died at city hospitals could be used for dissection.
Extreme measures ensued. It was not unheard of for an anatomist to tote freshly deceased family members over to the dissecting chamber for a morning before dropping them off at the churchyard. Seventeenth-century surgeon-anatomist William Harvey, famous for discovering the human circulatory system, also deserves fame for being one of few medical men in history so dedicated to his calling that he could dissect his own father and sister.
Harvey did what he did because the alternatives—stealing the corpses of someone else’s loved ones or giving up his research—were unacceptable to him. Modern-day medical students living under Taliban rule faced a similar dilemma, and, on oc
casion, have made similar choices. In a strict interpretation of Koranic edicts regarding the dignity of the human body, Taliban clerics forbid medical instructors to dissect cadavers or use skeletons—even those of non-Muslims, a practice other Islamic countries often allow—to teach anatomy. In January 2002, New York Times reporter Norimitsu Onishi interviewed a student at Kandahar Medical College who had made the anguishing decision to dig up the bones of his beloved grandmother and share them with his classmates. Another student unearthed the remains of his former neighbor. “Yes, he was a good man,” the student told Onishi. “Naturally I felt bad about taking his skeleton…. I thought that if twenty people could benefit from it, it would be good.”