Cutting Out the Cadaver
The anatomy teacher propped up half a human pelvis on the lab bench and swiveled it to give the seven medical students a different view. The chemically preserved specimen, expertly dissected, was fitted with color-coded wire tabs that identified the neatly displayed parts.
The students at UC San Francisco stood a respectful distance away. They took notes. They wore street clothes. And, unlike past generations of medical students who spent months dissecting cadavers, they did not touch the pelvis.
It’s a lot more efficient than “bushwhacking your way through the body,” said one student, 29-year-old Sydney Sawyer.
For nearly a century, the dissection of human cadavers has been a dreaded and honored rite of passage for budding doctors.
But over the last two decades, the field has lost prominence at medical schools -- the victim of overly packed curriculums, a shortage of teachers and a general sense that dissection is an antiquated chore in a high-tech world.
Most medical schools have scaled back the time students spend in the anatomy lab to give them more time to study molecular biology or genetics. A few have eliminated dissection as a requirement for being a doctor. When UCSF, one of the top medical schools in the nation, did away with the requirement two years ago, it sent shudders through the field of anatomy.
The future is moving toward ready-to-view, professionally dissected specimens (known as “prosections”) that allow students to scoot in and out of class with a minimum of mess, and computer simulations that do away with cadavers entirely.
“There’s a lot of problems with cadavers,” said Vic Spitzer, director of the Center for Human Simulation at the University of Colorado Health Sciences Center. “They are like leather. They smell. They’re oily. They’re hard to work with.”
But for many anatomists who learned the human body the old-fashioned way -- sawing, slicing and snipping away limb by limb, organ by organ -- the changes are a sad sign of medicine’s transformation from an ancient craft of hands and eyes to a sanitized science ruled by technology.
They lament that future generations will bypass a lifelong lesson of medicine: Putting a scalpel to a dead body confers a sense of higher purpose -- it is the gruesome price to pay for the privilege of someday working on a live one.
“The part that is so awful about it makes it so effective,” said Dr. Bert Thomas, an orthopedic surgeon at UCLA who graduated from medical school 25 years ago.
In Thomas’ time, anatomy was the most important course of the first year of medical school.
He had never seen a dead body before. The closest he had ever come to internal organs were a photographs in a college biology textbook.
“We called him Oscar,” Thomas said of the cadaver he studied. Oscar had suffered severe hardening of the arteries and died in his 70s. Thomas and his dissecting partners at the University of Pennsylvania kept the face covered as they proceeded over the months.
“I was one of the more distressed people,” Thomas recalled.
One day, after midnight, he returned to the basement lab alone to review the anatomy of the forearm. Dead bodies were spread across the tables. As he tugged on some tendons, Oscar’s hand curled behind Thomas’ arm and grabbed his elbow.
“I remember pulling on those tendons many years ago very vividly,” he said. “I remember the valves of the heart.”
Dr. Paul Schmit, another UCLA surgeon, can still remember the smell of the embalming fluid that seemed impossible to wash from his hands.
“Madame Ovary,” he said, reciting the name that a medical school classmate picked for their cadaver 23 years ago.
“Sasha,” said Dr. William Dignam, an 83-year-old retired obstetrician/gynecologist who could still recite the Latin names of all the hand bones even though he hadn’t studied them since medical school 60 years ago.
Human dissection has been a staple of medical education for decades, and a cornerstone of science for millenniums. The first recorded dissection was around 300 BC by the Egyptians, who were already well-versed in the craft of mummification.
But it was a 16th century Belgian anatomist, Andreas Vesalius, who transformed the discipline into a modern science.
He systematically dissected the human body, publishing his detailed account in the now classic seven-volume text De Humani Corporis Fabrica (On the Fabric of the Human Body).
He had to dissect covertly, because outsiders would certainly see his work as grotesque and unholy. But some scientifically minded Italian priests let him work in the backroom of a church. Later at the University of Padua, where he was a professor, he constructed a table that could be quickly flipped over, dumping the body underneath and revealing a splayed-open dog in case of any unexpected visitors.
Even up to the early 1800s in Britain, the only legally available cadavers for dissection were of executed murderers. In the United States, dissection was illegal, although medical professors considered it so important that they sometimes provided their students with bodies -- occasionally getting the aspiring doctors in trouble with the law.
Cadavers were in short supply. Medical schools bought them, which fostered a new industry: body snatching. The most entrepreneurial did not always wait until their targets were dead. In the famous Burke and Hare scandal, a boardinghouse owner in England conspired to murder several guests and sell their corpses.
Body snatching on both sides of the Atlantic was largely stopped by laws allowing medical schools to use unclaimed bodies as cadavers. But bodies were still in such demand that it was not unheard of for anatomists to dissect deceased members of their own families.
The U.S. cadaver supply did not stabilize until the 1950s, when UCLA pioneered a program to have people donate their bodies to science. Others soon followed.
Medical schools were ruled by their anatomy departments. Gradually, revolutions in genetics and molecular biology, along with improvements in clinical training, sharply increased the amount of material that had to be squeezed into four years of medical school. Anatomy and dissection began getting squeezed out.
Even its defenders concede that dissection is a mess.
Maintaining cadavers is expensive, from square footage to store them to ventilation systems to counter foul-smelling embalming chemicals. Some students suffer nightmares from working on the dead.
Teaching a dissection class requires intense supervision to keep students from accidentally mutilating the nerves and tendons they are trying to find.
In short, old-style dissection has come to typify what many critics believe was wrong with medical school.
“Half of what was being taught before was irrelevant to patient care,” said David Irby, a UCSF medical school dean.
But old traditions fade slowly.
Arched over yellowing flesh, Dora Castaneda, a first-year medical student at Stanford University, used forceps to pluck tiny pieces of fat from the right cheek. Working on the other cheek was Erik Cabral, her dissection partner, who also happened to be her fiance.
“She’s looking for arteries,” he explained. “I’m looking for nerves -- how you sense a kiss.”
For nearly five months -- twice a week in the fall, once a week in the winter -- they have dissected the woman. She died at age 57 of heart failure. Cabral peeled back a sheet covering the body to reveal a still life of scattered bones and organs. He picked up the heart, which was next to a knee, to show that the woman had undergone bypass surgery.
They also found that the woman suffered from gallstones. They kept the brain in liquid in a white bucket.
When they finish, they will participate in a service to honor the donors.
That in itself is a culture shift. In the old days, cadavers were not always treated respectfully. Some doctors and anatomy professors remember intestines being used to jump rope or stiff lips jammed with lighted cigarettes, pranks born from mix of testosterone and nervousness.
Dissection sensitizes and desensitizes. On the first day in the lab, the body is intact. “My first thought of her was as a grandmother,” said Mike Molina, another student, working a few tables down in the basement lab.
For the first two weeks of class, he struggled to sleep. But as the dissection proceeded, as limbs and organs were opened, he began to see her as a specimen.
Still, the humanity returns in ways big and small, when students uncover a face, or when they unwrap the hands to discover chipped nail polish.
While Molina was deep into the cheek, his partner Jeremy Juang only observed.
“I’m not going to be a surgeon,” said Juang, who is also pursuing a PhD in immunology. “I don’t want to spend much time digging and getting all dirty.”
Dissection class at Stanford is a lot cleaner than it was just a year ago.
The school instituted a 25% reduction in the time students spend in the lab. Now the instructors do much of the most tedious work -- removing skin from the back and the palms and sawing through craniums, for example -- leaving students with the more intellectually stimulating tasks of searching for nerves and arteries.
UCSF -- and a few lesser-known schools -- have gone further. Most medical students there do not seem to mind that dissection is no longer required.
“I am going to save 100 hours not dissecting,” said Alon Unger.
“I don’t think I would have got a lot out of cutting through fat and fascia,” said Jason Wagner.
“I don’t really enjoy standing next to a dead body,” said Anna Lyapis.
UCSF still has an impressive anatomy lab, with a 13th-floor view of the Golden Gate Bridge and a large collection of bodies laid out on the tables. As has long been the tradition, dentistry students are still required to perform complete dissections. Surgeons also practice here. And nearly a third of the medical students choose to take a once-a-week elective in dissection.
But most anatomy lessons are incorporated into other courses and taught with computer programs and prosections.
Some medical schools have begun to incorporate virtual dissections into their curriculums.
One aid is the Visible Human, a computer program developed at the University of Colorado. The program features anatomical images taken from a cadaver -- an executed murderer from Texas -- that was frozen, then sliced into 1,871 1-millimeter cross-sections.
Starting this fall at more than two dozen medical schools, students will be able click away layers of tissue or entire organs from a 3-D image.
Chinese researchers recently cut a body into 0.1-millimeter slices. Such advances will allow finer resolution in computer models. The aim is to combine that imagery with virtual reality technology that would allow students to feel the weight, texture and elasticity of body parts without a whiff of formaldehyde.
For all the technological advances, anatomists wince at the notion that a computer simulation or video lessons could one day replace a real body.
Computers, they say, cannot recreate the experience of unveiling a heart, of witnessing firsthand all the anatomical variations in people, of seeing how the parts of the body form the whole of a human being.
“We’ve been dumbing down medical students, anatomywise, for the last 20 years,” complained Robert Trelease, who teaches anatomy at the UCLA School of Medicine.
Arthur Dalley, head of anatomy at Vanderbilt University, which has firmly defied the trend, said some young doctors are so uncomfortable with the vagaries of the human anatomy that they have come to rely more on instruments and tests than their hands to conduct routine physical examinations.
“I think it’s heartbreaking,” he said.
The decision at UCSF to eliminate the dissection requirement two years ago has reverberated through medical schools nationwide. Anatomists say they feel increasing pressure from administrators to condense dissection.
“I think there’s a bottom line,” said Dr. John Gosling, who teaches anatomy at Stanford, “and I think we’ve reached it.”
Todd Olson, an anatomy professor at the Albert Einstein College of Medicine in New York, where dissection is required for all students except those also pursuing PhDs, felt that scrapping dissection could lead to less compassionate doctors.
But whether cutting up a dead body makes a more sensitive doctor is open for debate.
Increasingly, there are fewer people to champion dissection’s cause.
Few academics are willing to dedicate themselves to teaching an ancient field when university careers are increasingly driven by cutting-edge research.
The luminaries on campus these days are working in immunology, cancer and genetics.
“Training in anatomy pulls you out of the research lab,” said Rick Drake, who heads pure prosection anatomy training for MD and PhD candidates at Case Western Reserve University. “Nowadays, to get promotion and tenure, you need to be doing research.”
In a 2002 survey by the American Assn. of Anatomists, 83% of department heads who responded said they would have great or moderate difficulty in finding qualified new teachers over the next five years.
The defenders of dissection are left pondering their own mortality. At Stanford, all three anatomy teachers are about 60.
“The three of us are at the end of our careers,” Gosling said. “We will be difficult to replace.”