Writer, M.D.

by Leah Kaminsky

  During those early weeks some of my classmates and I began to have dreams about anatomy lab. Some had peaceful dreams in which they held hands with their cadavers or shared a meal. Others were less romantic or downright frightening. My dream, likely fueled by a childhood appreciation of Edgar Allan Poe, remains vivid in my memory. I find myself alone in the laboratory, pacing the hall. The doors of the supply closets that line the hallway swing open suddenly, and cadavers partially dissected and exhibiting signs of putrefaction hang on hooks in each closet. As I try to run away, the closet doors keep opening and closing. Afraid that one of the cadavers will fall on me, I frantically try to escape; but a relentless echoing heartbeat pursues me, growing louder as I run down the hallway.

  That morning I woke up exhausted. After a few minutes I realized that the heartbeats I had heard were the reverberations of my own pulse pounding in my ears.

  As the weeks passed many of my classmates resorted to black humor. Medical versions of urban legends made the rounds of our laboratories, as they did in medical schools throughout the country. One story was of a medical student who stole a hand and took it to a bar for a variant of the “can you lend me a hand” visual gag. Another story took place at a stadium’s urinals with a couple of men, a male medical student, and another stolen anatomic part. One classic legend, probably passed among medical students for generations, had the medical student “friend of a friend” completing dissection on the entire body, only to find upon uncovering the cadaver’s face that she had been dissecting her uncle.

  Some of my fellow students became increasingly dependent on humor of any kind to lighten the mood in the laboratories and to ease personal anxieties. One group of students brought recordings of old television show theme songs to play while dissecting. Another student adopted the ritual of coming around to each of the four tables in our lab room and playing his air guitar at the beginning of each dissection period. For a while it seemed as if no afternoon could go by without Ben first jamming on that guitar, his thin long face contorted as he lip-synched some classic hard-rock tune playing in his head. Midway through that first semester, however, he and his air guitar suddenly disappeared; Ben had quit medical school.

  The daily confrontation with a dead body, the first stranger’s body that medical students may have ever examined so closely, marks a point of high anxiety in medical education. Ruth Richardson, in her classic book Death, Dissection, and the Destitute, writes, “[D]issection requires in its practitioners the effective suspension or suppression of many normal physical and emotional responses to the willful mutilation of the body of another human being.” Traditionally medical schools have rarely addressed such psychological concerns; instead educators have only acknowledged the difficulty of mastering the detailed anatomic knowledge. Taking the cues from their teachers, medical students learn to deny their own feelings, depersonalizing the dissection experience and objectifying their cadaver. They strip away the cadaver’s humanity, and soon enough they are dissecting not another human being but “the leg” or “the arm.”

  There are other not-so-subtle clues that reveal the psychological impact of the experience. The frequent cadaver dreams show how profoundly the experience affects the psyche. The use of black humor allows students to deny the significance of any emotional strain. The medical urban legends allow one to hear about someone else’s more horrifying experience and thus put one’s own experience in a lesser, and therefore more easily palatable, position. At times the denial becomes so great that young medical students are unable to express even their grief. When their emotions are finally released, the manifestations are strangely inappropriate. Ellen Lerner Rothman, M.D., writes in her memoir of her four years at Harvard Medical School:

  At times, it felt as if death were everywhere. In anatomy lab, we finally uncovered the facial shroud and opened the skull to dissect the brain, and that was okay. I talked to a patient who had nearly died the previous evening and would certainly die within the next months, and that was okay. I came home, and my goldfish had died, and that wasn’t okay. I sobbed for half an hour.

  Even medical students chosen for their humanitarian qualities and selected from a huge pool of applicants may have their generous impulses profoundly suppressed by their medical education. Some students misinterpret their painful reactions to the dissection process as abnormal and abort their budding medical careers, incorrectly assuming that they have entered the wrong profession.

  There are experts in medical education who theorize that the dysfunctional coping mechanisms traditionally used by medical students in their anatomy courses can lead to inappropriately unsympathetic bedside manners. To encourage the development of more effective and desirable attitudes, medical schools have begun to broaden the human anatomy curriculum and have taken steps to mitigate the emotional difficulties. For example, more schools are now holding memorial services for the cadavers at the end of the anatomy course, providing students with an opportunity to express their emotions and gratitude. During these ceremonies, students perform musical pieces and read poems and essays they have written about their cadavers. Some schools have incorporated death-and-dying education into the human anatomy curriculum, drawing on the humanities to generate discussion in small groups and encouraging students to use writing and the fine arts to express their emotions. Still others, plagued by a perpetual shortage of cadavers donated for science, contemplate eliminating dissection altogether, limiting anatomy, and perhaps the student’s first encounter with a patient, to a computer-generated experience.

  Over the course of the next week our class dissections centered on the perineal and inguinal, or groin, areas. The layers of muscle and fascia around the rectum, vagina, penis, urethra, and groin overlap and undulate in confusing ways. Despite the careful dissection work on our cadavers, many of us remained frustrated. In fact, it was not until my next-to-last year of surgical residency that I fully understood the many layers and folds of tissue encountered in an inguinal hernia repair.

  That fall my classmates and I brought our anatomy texts to the library, the conference rooms, the cafeteria, and the subways and stared at the pictures, trying to commit all the parts to memory. A German anatomy atlas became particularly popular during this segment of our course. Instead of paintings or drawings, this book featured photographs of actual cadaveric dissections. Despite the fact that all the named parts looked ragged from preservation and were of an indistinct beige or gray, some of us believed that these books would help us on exams. On full display wherever we were studying, these atlases would be flipped open to photographs of dissected, spread-eagled, cadaveric male and female genitalia. One classmate realized she had become hardened to these depictions when she looked up from her anatomy books and noticed other passengers on her train commute home moving silently away from her.

  Male cadavers were rare that year, so we all crowded around the lab groups who had males to watch the dissection of the male external genitalia. One student read from the Gray’s Anatomy lab instruction book, the bible of anatomic dissections, while another performed the necessary incisions and maneuvers. It was usually the women who held the scalpel during this part of the dissection. I watched my male classmates wince and shift uncomfortably; there were some areas of the body where we could not, try as we may, separate our own feelings from the science of discovery.

  The final maneuver of this section of anatomy would, according to our professor, “bring all the concepts together visually.” Divide the pelvis sagittally, our Gray’s Anatomy lab instruction book directed. That afternoon in the laboratories we passed around an electric saw similar to the one my father used for carpentry at home. My lab partners were not sure that we understood what we had read. To our disbelief, we did: we would need to bring the saw down the middle of our cadaver’s pelvis and divide it. While this step did indeed expose pelvic anatomy in a way that no other dissection would, I could not bring myself to take the saw to our cadaver. Even after having filleted her arms and legs i
n previous weeks, I had difficulty with the idea of sawing a part of her in two. Realizing that three of us could not do it, Mary, the calm one who would become a family physician, took the saw in hand. She closed her eyes for a moment and then drew the spinning blade down from the center of the symphysis pubis to the strip of flesh between the buttock cheeks. Our cadaver’s pelvis, now split, fell apart, the legs turning outward like those of a dancer in the first position. Mary turned off the saw, handed it to the next group of waiting students, and remained silent for the rest of the afternoon.

  Since medical school, I have loved gazing at historical lithographs of human anatomy. Tucked away in ancient book stacks in medical libraries, sold in overstocked antiquarian bookstores, or displayed in stands along the Seine in Paris, the pictures are not always anatomically correct, but they are always amusing for their profusion of detail and over-the-top quality. The ones from the Renaissance are often accessorized with ornate calligraphy, the tails of letters curling coyly around the borders. The cadavers are artfully posed, as if about to give a lecture or smell a flower, seemingly unconcerned that their innards are hanging out on full display.

  Despite the existence of such lithographs for centuries, public acceptance of human cadaver dissection as a part of medical education is a fairly recent phenomenon. For much of their history, anatomists and physicians worked illegally and surreptitiously, lying, cheating, stealing, and even murdering to further their academic cause. The Council of Tours openly prohibited human dissection in 1163. While their edict was directed more at the practice of dismembering and boiling the remains of dead Crusaders for shipment home, the early Christian beliefs regarding postmortem manipulations were clearly reflected in this decree. After all, the resurrection of the body would be impossible if it had been dissected and therefore desecrated.

  During the Renaissance there was a surge of interest in anatomy. Leonardo da Vinci, for example, studied human anatomy in great detail. In 1510 Leonardo completed work that displayed the parallels between human and animal musculature, but his drawings remained unpublished during his lifetime. Andreas Vesalius, the acknowledged father of modern anatomy, performed his own cadaveric dissections and published the seven-volume masterpiece De Humani Corporis Fabrica in 1543. His meticulously accurate work revealed that earlier, previously accepted classical authorities such as Galen had been incorrect. Because of religious taboos, the classical anatomists had based their human portraits on animal anatomy.

  After the Protestant Reformation in the sixteenth century, London’s Royal College of Physicians received the legal authority to dissect human cadavers, but their corpses were limited to those of hanged felons. Dissections at the time were seen as the ultimate punishment for criminals, far worse than a death sentence alone. Even with the corpses of felons, however, the English medical community remained short of cadavers; and surgeons and anatomists resorted to purchasing bodies from grave robbers or “resurrectionists,” individuals who exhumed the recently deceased from their graves.

  During the nineteenth century Edinburgh was the center of research in anatomy, and Dr. Robert Knox attracted crowds of five hundred or more to his anatomy lectures. The number of aspiring physicians entering the specialty of surgery was also increasing because of the growing respect and honor accorded this profession. The medical school’s anatomy and surgery course lasted sixteen months, and students were required to dissect a minimum of three corpses in order to become licensed surgeons. All of these factors further taxed the limited supply of cadavers.

  Despite his illustrious reputation, Knox was believed to have remedied this shortage by purchasing bodies from two resurrectionists, William Burke and William Hare. While Burke and Hare did steal corpses from graveyards, they became infamous for having murdered as many as sixteen people in order to sell the bodies. Given the lack of an adequate tissue fixative and ensuing problems of decay, anatomists at the time preferred “fresher” corpses, and the corpses from Burke and Hare were among the most desirable. The two men had devised a technique of asphyxiation that left the cadaver relatively free of any signs of violence. This technique came to be called “burking,” a term that eventually worked its way into colloquial English because of the magnitude of the ensuing scandal.

  In 1829 Burke was found guilty of murder. His partner, Hare, escaped the death sentence by giving evidence against Burke during the trial. Burke was hanged in front of thirty thousand people, and his body was, rather appropriately, made the subject of a public dissection. His death mask and a wallet made from his tanned skin remain on display at the Anatomy Museum of the Royal College of Surgeons in Edinburgh. As for Dr. Knox, investigators were never able to prove his role in the multiple burkings, but suspicion was so high that the previously esteemed professor was driven out of Edinburgh amid a public frenzy.

  In response to the outcry and a subsequent case of burking in 1831, London passed the Warburton Anatomy Act of 1832, which ended the use of dissection as a punishment for murder and gave anatomists unlimited access to unclaimed pauper bodies from workhouses and hospitals. This law ultimately increased the supply of corpses, but many believed that it also transferred the worst punishment for criminals over to the indigent.

  In the New World the same social and political forces were at work. While human cadaver dissections took place in America as early as 1638, the demand for cadaver sources began to increase in 1745, when the first formal course in anatomy was offered at the University of Pennsylvania. The only cadavers available legally, however, were the bodies of executed criminals; dissection was used as a form of supra-capital punishment, just as in England. In 1784, for example, to discourage dueling, a Massachusetts law proclaimed that a slain duelist could be either buried without a coffin in a public place and with a stake driven through his body, or given to a surgeon for dissection. Six years later federal judges gained the right to add dissection to the death sentence for murder.

  When American medical schools began proliferating in the early nineteenth century, grave robbing became rampant as the demand for cadavers rose. The public became enraged by these acts of desecration and took to the streets in almost a dozen riots between 1765 and 1852. In April 1788, for example, children playing on the streets peered through the windows of the Society of the Hospital of the City of New York and saw medical students dissecting human cadavers. Their parents became outraged when they investigated and saw the dissected corpses. One child’s father even discovered that his late wife’s corpse, robbed from the grave, was among the dissected. A mob of five thousand stormed the hospital and the jail where several of the doctors had fled to take refuge. A three-day riot ensued, the laboratory was burned down, and seven rioters were killed. The militia finally dispersed the crowd by firing muskets. In response to these riots, New York passed a law in 1789 that allowed doctors to obtain human cadavers without resorting to body snatching.

  By the end of the nineteenth century most states had passed laws that allowed medical schools to obtain unclaimed bodies. The impetus for these laws came in 1878, when U.S. Senator John Scott Harrison, the son of President William Henry Harrison and father of President Benjamin Harrison, died and was buried in Ohio. Soon after Senator Harrison’s funeral, his son and nephew received word that the body of a family friend, William Devin, had been stolen from its grave and taken to the Medical College of Ohio. The two men went to the anatomy laboratory of the medical school to look for Devin. Instead, they found the body of Senator Harrison about to undergo dissection.

  By 1968 all fifty states had adopted the Uniform Anatomical Gift Act. This act ensures that a donor can bequeath his or her body to medical science and education. Since then medical schools have decreased the number of unclaimed bodies used, and the majority of cadavers studied now are the result of conscious and thoughtful decisions made by individuals prior to death. Nonetheless, the ongoing need for bodies and anatomic parts has created latter-day resurrectionists. Two recent cases of body parts being sold—by employees at a
California medical school and by a dentist and funeral home director in New York—remind us of nightmares rooted in our collective history.

  Despite the difficult history of anatomy, the act of dissecting a human cadaver—of feeling and seeing and holding the human body and its parts—remains fundamental to medical education. For physicians, the experience remains one of the most transformative in their early professional lives.

  We moved next in our anatomic journey to the torso. To acclimate our tender hearts to the grisly task, our teachers instructed us to start with the more impersonal back muscles. With fresh blades on our scalpels, we sliced through and peeled away the skin and subcutaneous layers, exposing the pale reddish-brown muscle fibers. The group across from us had a hulking male cadaver who had died in the prime of life. The muscles on his back were large and developed and reminded me of the big chunks of meat I had seen in the butcher’s section of the local supermarket. From that point on in my life, I had little enthusiasm for eating red meat; it never tasted the same again.

  In contrast, my cadaver had little if any muscular development, and I wondered if my own scrawny back was like hers. Compared to the other cadavers, particularly the males, my cadaver’s back muscles seemed barely large enough to have once held her torso erect. Some of her muscular structures were so small that I felt as if I were imagining rather than really seeing the muscles I had read about in my anatomy instruction book. While the larger straps of muscle on my classmates’ cadavers were easier to study, I felt possessive of my cadaver and became almost defensive about the tiny strings of tissue that crossed her spine and rib cage.

  After dissecting these muscles, we turned our cadavers on their backs and began work on the chest. My three female lab partners and I dissected the breasts particularly gently. We had read about Cooper’s ligaments, strings of nearly invisible tissue that suspend the glands, and the complicated ductal system. Much to our dismay, however, we found that the inner tissue of the breast was yellow and globular, not that dissimilar from the fat that we found in other parts of the body. The special ducts and glands that made milk for babies looked just like chicken fat with white, tenuous, connective tissue strings interspersed. It all appeared bland and nondescript.