All That Remains

by Sue Black

  At first, the embalmed muscle appears to be a uniform light brown mass (disarmingly, slightly reminiscent of tinned tuna fish), but as you look closer, and your eye starts to attune to its patterns, you can make out the orientation of its fibres and the thin strings of the nerves that supply it. You locate the origins and the insertions of the muscle and deduce its action on the joint it crosses, captivated now by the wonderfully logical engineering you are examining. As a living person, you remain separate from death, but the mesmerising beauty of human anatomy has created a bridge into the world of the dead, one that few will cross and none who do will ever forget. The sensation of traversing that bridge for the first time is an experience you can never repeat. It is special.

  The study of anatomy polarises its students: they either love it or they hate it. The fascination lies in the logic and order of the subject; the downside is the vast amount of information to be learned – that and the smell of formalin. When the fascination outweighs the drawbacks, anatomy imprints itself on your soul and you will consider yourself for ever a member of a privileged elite: the select few who have seen and been taught the secrets of human construction by those who have chosen to allow you to look inside their own bodies. We may stand on the shoulders of scholarly giants, Hippocrates and Galen, and their descendants Leonardo Da Vinci and Vesalius, but the real heroes are undisputedly those extraordinary men and women who choose to bequeath their mortal remains so that others may learn: the anatomy donors.

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  Anatomy teaches you many things beyond the workings of the corporeal form. It teaches you about life and death, humanity and altruism, respect and dignity; about teamwork, the importance of attention to detail, patience, calmness and manual dexterity. Our interaction with the human body is tactile and very, very personal. No book, model or computer graphic will ever come close to dissection as a means of learning our craft. It is the only way to do it if you are to become a card-carrying anatomist.

  It is, though, a subject that has been much maligned as well as revered in its past. Since the glorious years of the early anatomists, from Galen to Gray, right up to the present day, it has been tainted periodically by nefarious characters who have sought to exploit it for profit. In nineteenth-century Edinburgh, the heinous deeds of Burke and Hare, who turned to murder to supply cadavers to anatomy schools, led to the passing of the Anatomy Act of 1832. As recently as 1998, the sculptor Anthony-Noel Kelly was jailed for stealing body parts from the Royal College of Surgeons in a case that cast a spotlight on the ethics of art and the legal status of human remains donated to medical science. And in 2005, an American medical tissue company was closed down after its president was convicted of illegally harvesting body parts and selling them on to medical organisations. It seems that anatomy is not immune to the economics of supply and demand, or to the criminal acts of a few racketeers with no regard for decency, dignity or decorum. It is right therefore that we defend our donors and that they are protected by an Act of Parliament.

  There is money in death, and where there is money to be made there will always be those prepared to cross ethical boundaries to make more of it. Given that the sale of human remains is legal in many countries and that a good number of institutions around the world will pay a hefty price even for an articulated human skeleton, perhaps it should not surprise us that the ancient crime of grave-robbing persists in modern-day forms. When I was a student in the 1980s, most of the teaching skeletons used in dissecting rooms were imported from India, long regarded as the world’s primary source of medical bones. Although the Indian government outlawed the export of human remains in 1985, a global black market still thrives there today. In the UK, we have rightly become intolerant of the sale of bones or any other body parts.

  What is or is not considered acceptable in terms of the treatment of human remains fluctuates, like all social attitudes, and can sometimes change quite markedly in the course of a single lifetime. The skeletons currently used to teach UK anatomy students are more likely to be plastic replicas, and although human ones can still be found in the dusty old cupboards of school science labs, GPs’ surgeries and first-aid training facilities, many organisations that possess them quite legally are uncomfortable nowadays about holding on to them. Some opt to donate them to a local anatomy department and in return they might be offered an artificial teaching skeleton as a replacement.

  Unlike our predecessors, contemporary anatomists can take time over dissection and thus gain far more value from our cadavers in our study of the infinitesimal detail of the human form, thanks mainly to centuries of research into ways of preserving the human body and halting the process of decay. Since the early days of dissecting corpses freshly cut down from the gibbet, anatomists have striven to preserve cadavers for as long as possible by following the techniques developed by the food industry, learning how to pickle in alcohol or brine or how to desiccate and freeze.

  After Lord Nelson’s death in the Battle of Trafalgar in 1805, his body was stored in a vat of ‘spirit of wine’ (brandy and ethanol) for his journey home to a hero’s funeral. Pickling alcohol remained the preferred method of preservation until the discovery of a nasty chemical called formaldehyde later in the nineteenth century went on to transform the field of anatomy. Formaldehyde is a disinfectant, a biocide and a tissue fixative and works so well that its aqueous solution, formalin, is still the most commonly used preservative worldwide.

  But in sufficient concentration formaldehyde is a hazard to human health and recent decades have seen alternatives being considered. These include fresh-frozen cadavers, where the body is dismembered into parts that are frozen and then thawed as required for dissection, and soft-fix methods that leave the body more supple and closer in texture to a living human. In the 1970s, the anatomist Gunther von Hagens pioneered plastination, whereby water and fat are removed under vacuum and replaced by polymers. These body parts have eternal life. As they will never decompose, we have succeeded in designing a new environmental pollutant.

  Whatever advances there may be in the technology we use to preserve bodies or to investigate them through medical imaging, anatomy itself, of course, does not change. What was seen in the cadavers dissected by Vesalius in 1540 or by Robert Knox in 1830 was, in essence, no different from what Graham and I saw during the academic year we spent with Henry. However, as Vesalius and Knox were obliged to dissect fresh remains, the very limited time they had with a cadaver probably did not engender the same bond of trust and respect between the dissector and the dissected that I was fortunate enough to be able to establish with Henry. Or maybe it is just that social and cultural attitudes have changed down the years.

  For me there can never be another Henry, and for every anatomist their own Henry will be special. I learned so much in that year about myself as well as about the human form. At those stages in our lives when we look back to pinpoint the times that made us happy and fulfilled, my search will always lead back to Henry. There are few moments in that year that I would trade, but I would be lying if I said there were none. I hated cutting through the beds of his fingernails and toenails as I always felt, irrationally, that it would hurt. And to be honest, nobody enjoys flushing out the digestive system.

  But for me the rewards to be gained from the study of the dead far outstrip those less palatable moments, and the gut-wrenching fear that kicks in when you become properly aware of the sheer volume of what you need to master: over 650 muscles must be committed to memory, along with their sites of origin and insertion, their nerve supply and their actions; more than 220 named nerves, their root values and whether they are autonomic, cranial, spinal, sensory or motor; hundreds of named arteries and veins that spread in an arborescent pattern from the heart and back again, their origins, their divisions and the related soft-tissue structures. Then there are the 360-plus joints, and don’t get me going on the three-dimensional relations of the developing gut, tissue embryology, neuroanatomy and its tracts.

  Just when you think you a
re getting to grips with some of these anatomical structures, they skip from your fingers like soap in the shower and you have to start all over again. Utterly infuriating. But the reiteration of mountains of facts and connections is the only way to learn and understand the three-dimensional complexity of the human. Anatomists don’t have to be particularly clever: they just need a good memory, a logical learning plan and spatial awareness.

  Henry allowed me to probe into every detail of the workings of his body, to explore his anatomical variations (bless him and his aberrant superficial epigastric artery – I will never forget that!), to get frustrated when I cut through something when I should have known better and helped me to wrestle with the virtually invisible parasympathetic nervous system. He bore it all with fortitude, never scolding me or making me feel foolish, and in time the balance tipped to a point where I was learning more about him, in one sense, than he might ever have known about himself.

  I discovered that he didn’t smoke (his lungs were clear), he didn’t drink to excess (his liver was in very good condition), he was well nourished but didn’t overeat (he was tall and slim, with little body fat, but not emaciated), his kidneys looked healthy, his brain showed no tumours and there was no evidence of aneurysm or ischaemia. While his cause of death was listed as a myocardial infarction, his heart looked strong to me. But what did I know? I was just a third-year rookie.

  Perhaps he died simply because it was his time to die, and something likely had to go down on his death certificate. The cause of death given for a cadaver often elicits concern in our students when, on coming to examine the organ in question, they find no disease or abnormality. When death is due simply to old age and it is known that the deceased desired to bequeath their body, the recorded cause of death will inevitably be reasoned and educated supposition. The only way to establish it for certain would be to perform a postmortem which, as this procedure renders the body useless for dissection, would contravene the wishes of the donor. So as long as the death is not suspicious and is consistent with the age of the deceased, in many cadavers the cause will have been rationally deduced as heart attack, stroke or pneumonia – dubbed by some the old person’s friend.

  By the time we had finished cataloguing Henry’s body, all the way from the top of his head to the tip of his little toe, there was no part of him we had left unexamined. No part that we had not pored over in books, debated, checked and confirmed. I was so proud of this man I would never know as a living, breathing, talking, active person but with whom I was now so personally and intimately familiar that I felt I knew him in a way nobody else ever had, or ever would. What he taught me has stayed with me, and will stay with me, for ever.

  Within a few months, it would be time to say goodbye and to promise Henry that I would put the education he had given me to good use. I bid him a final farewell at King’s College chapel in Aberdeen at a moving service of thanksgiving for the gift of our bequeathers, attended by their families and friends, staff and students. I couldn’t know, when the names were read out, which one was Henry’s. From my hard, wooden seat in the choir stall, I scanned the faces of the congregation, wondering which of the grieving relatives was shedding a tear for him. Which of the people sitting on those well-worn pews had been his amicus mortis, his friend in death? I so hoped he hadn’t died alone. It is more comforting to think that someone dear to him had been at his side to hold his hand and tell him he was loved.

  All of the Scottish anatomy schools arrange these services every year. They allow us to pay our respects and demonstrate to the families and friends of the bequeathed just how crucial their gift has been, how much it was valued and how important in fostering the education of the next generation.

  CHAPTER 2

  Our cells and ourselves

  ‘Without systematic attention to death, life sciences would not be complete’

  Elie Metchnikoff

  microbiologist (1845–1916)

  A CT scan of the skull showing the position of the otic capsule at its base.

  WHAT MAKES US human? One of my favourite definitions is: ‘Humans belong to the group of conscious beings that are carbon-based, solar system-dependent, limited in knowledge, prone to error and mortal.’

  It is strangely comforting to be granted tacit permission to make mistakes just because we are human. As we possess neither the capability to get everything right first time nor an unlimited lifespan at our disposal to practise and hone each task to perfection, we should accept that our lives will be a bit of a mixture. Some tasks we will fulfil well and they will enrich our lives and the lives of others; those we will clearly never master are just a waste of our precious time.

  There is a lovely moment in the film When Peggy Sue Got Married which epitomises the human desire for glimpses into the future to help us focus our attention today on what will ultimately prove worthwhile – or not. ‘I happen to know that in the future,’ Peggy Sue tells her teacher after a maths test, ‘I will not have the slightest use for algebra – and I speak from experience.’ Forward planning when we have no idea what lies ahead of us is tricky and, while it can seem unimportant when we are young, as we near our allotted three score years and ten, life seems to speed up and we begin to become aware of how much we still have left to achieve.

  The ‘conscious’ aspect of being human is perhaps our most defining characteristic. This centres on our knowledge of ‘self’ – the almost unique ability to display introspection, and thereby to recognise ourselves as separate individuals from others. The psychology surrounding identity and recognition of ‘self’ is extremely complex. In the 1950s, the developmental psychologist Erik Erikson summarised identity as: ‘Either a) a social category, defined by membership rules and (alleged) characteristic attributes or expected behaviours, or b) socially distinguishing features that a person takes special pride in or views as unchangeable but socially consequential (or a) and b) at once).’

  Researchers believe that a sense of identity is a manifestation and extension of the maturation of the concept of self which allows us to develop an intimate and intricate society. It enables us, to a certain degree, to express individuality, and perhaps helps others to tolerate it, by permitting us to both promote and display who we are, who we want to be and what we choose to stand for. Thus we can actively draw like-minded people around us and repel those with whom we do not, or do not wish to, identify. This freedom of individuality, and indeed its suppression, gives humans a unique capability and opportunity to play with their identity and to manipulate, or even change, the perception, portrayal and concept of ‘self’. It is here that I think Erikson omitted the third and most important category of identity, and the one that is most fun to play around with: physical identity.

  If, as a species, we recognise the physical differences between self and others, then we can use this ability to try to differentiate between any two individuals. The importance of identity in our society, and the fact that it can be manipulated, places it at the core of investigative sciences, including my world of forensic anthropology – the identification of the human, or what remains of the human, for medico-legal purposes.

  How can it be proved, using our innate human biology or chemistry, that we are who we say we are, and that who we say we are is who we have always been? Forensic science can be used as a toolbox of techniques to reconcile an unidentified body with its previous living identity. Forensic anthropologists look to features of our corporeal biology or chemistry to analyse a trackable and readable history of the life lived, and to confirm whether the evidence recovered matches traces left by that person in the past. In other words, we search for clues of the narrative written in our bodies, innate and acquired, laid down between birth and death.

  From a much more pedestrian biological perspective, the human can be rather crudely defined as a large mass of self-regulating cells. If histology, the study of the microscopic anatomy of the cells and tissues of plants and animals, and the cell cycle have never got me terribly excited
– there is just far too much complex biochemistry involved for my simple little brain to compute or to be bothered with – we must acknowledge that the cell is the basic unit of all known living organisms. So if death is going to be held responsible for the end of an organism’s existence, then she is also going to have to take the rap for the death of every cell. Anatomists know that ultimate organismal death can often be traced from the cell to the tissue and then to an organ or an organ system. So, whether we like it or not, it all begins and ends with cells. Death may be a single event for the individual but it is a process for the body’s cells, and to understand how that works, we must be familiar with the life cycle of the building blocks of the organism. Stay with me – I promise it won’t be too boring …

  Every human is created when two separate cells fuse and then begin to multiply – an incredibly humble beginning from an unimpressive little sack of proteins. After forty weeks in utero, those two cells will have gone through the most miraculous transformation, becoming a highly organised mass of over 26 billion. The huge increase in the size of the fetus and in the specialisation of its individual components requires a tremendous amount of precise planning if everything is to go as it should, and, thankfully, much of the time it does. By the time that baby becomes an adult, the cell mass will have expanded to over 50 trillion, grouped into some 250 different cell types forming four basic tissues – epithelial, connective, muscular and nervous – and a variety of sub-tissues. These in turn will combine to construct approximately seventy-eight different organs, divided into thirteen major organ systems and seven regional groupings. Remarkably, only five organs are considered vital to sustained life: the heart, brain, lungs, kidneys and liver.