Cause of Death: Finding Purpose in Medical Cadavers

            The doctor’s office is a place we are all familiar with (that’s not to say we necessarily enjoy the visit, especially having to reschedule our entire Tuesday afternoon’s to hit that 3:00 PM timeslot). But outside of the slight inconveniences of afternoon traffic or the curse of a perpetually late doctor, our contemporary medical practices are a remarkably pain free. Once invasive procedures can like open heart surgery can now be performed via laparoscopic catheters – the process of inserting a microscopic camera and knife mounted a thin plastic tube through the femoral artery¹. Astoundingly the process leaves only two quarter inch scars on the inside of the thigh a stark contrast to the broken ribs and sternum long scar from classical open heart surgery¹. These ‘Minimally Invasive Surgeries’ as they are known are less time intensive, have nearly half the recovery time, and most importantly have a significantly increased survival rate relative to more invasive and traditional methods². Many of the bounding advances in our new age of medicine have the digital age to thank. In the case of minimally invasive heart surgery, the success of the laparoscopic process rests entirely on the development of the compact and high-definition cameras used – most laparoscopes span roughly 5 mm or half the size of your pinky fingernail².

(Example laparoscopes, 5mm and 10 mm sizes. Source: http://www.veterinarylaparoscopy.com/userimages/laparoscopes1.JPG)

The veritable effects of these new heart procedures can be witnessed in the turnaround of the Seattle area medical community, which in the late 90s began embracing these emerging digital technologies, implementing newer tools and techniques across the greater Western Washington area³. Now thanks to the work of the Virginia Mason Medical Group and the University of Washington Medical School the Pacific Northwest ranks as first in the nation for heart attack, heart failure and stroke treatment, a microcosmic testimony to the medical revolution we are living in today³.

Sixteen short years into the 21^st century, we’ve constructed an understanding of the human body never before conceptualized. We have the astounding capability to image, examine and heal the body more efficiently and effectively than over more than eight millennia of recorded medical practice. We now possess ability to detect and decipher even the most fickle of diseases or earliest stages of cancer – thanks to recent developments in digital imaging like positron emission technology. As doctor and author Eric Topol notes in his novel The Creative Destruction of Medicine, the far reaching results of digital technology have spurred overwhelming enthusiasm within the medical community⁴. Topol’s sweeping interviews investigate a wide range of opinions in virtually every specialty of medicine practiced today, and the consensus is clearly for digital medicine⁴. And to mirror the novel’s subjective social consensus, more objective scientific studies have been assembled by the National Institute of Health investigating this very advancement⁵. The findings show digital medicine having a significant impact across medical fields in terms of patient care, quality of treatment, and so on – proof that Seattle’s cardiology boom isn’t so much an outlier, but a trendsetter⁶. Save for minor arguments relating to the cost of more expensive digital machinery operating expenses⁷ (which in truth is more a political-funding issue than a medical concern), for doctors and patients alike, there is little reason against modernizing medical practices for a digital age.

However there is one gross exception to this digital movement: gross anatomy.

As nearly every facet of our medical community moves towards a digital medium, there in suit has been a growing movement towards digitizing medical cadavers, the bodies that make up Gross Anatomy. For all the good that the digital world brings to medicine, it is not a one-size-fits-all improvement that extends to the paramount course that is cadaveric dissection. In fact more damage is being done to the quality of our emerging doctors than is benefited from the digital transition. The anatomical education every medical student receives in gross anatomy – whether a future physician or brain surgeon – is absolutely essential for every healthcare professional, as the body is inherently their specialty in one capacity or another. Today in the pro-digital movement, there is a faction of medical professionals and universities attempting to altogether abolish the practice of cadaver dissections, favoring digital and virtual reality teaching components instead⁸.

(Virtual Reality Dissections in action.)

On the surface level this anatomical digitization a result of our trend towards our digital medical era. And while this recent technological boom certainly has influenced the burgeoning of digital dissection platforms and virtual reality anatomy, the fundamental shift away from cadaver dissection stems from a much deeper cultural relationship - and fear - of death. But in spite of the cultural taboos, the dissection of human bodies isn’t a simply archaic tradition, but a critically formative experience to young doctors that simply cannot be replaced by a digital model. Notwithstanding of all the positive effects that digital medicine has on our health as a community at large, gross anatomy is the fundamental aspect of medicine that cannot be digitized. To fully understand the complicated relationship we as a society have to medical cadavers today, we must first look to the origins of human dissection itself. In its most primordial state, the first evidence of ‘medicine’ or ‘surgery’ appears circa 7000 – 6500 BCE in trepanned skulls, the iconic craniums with surgically bored holes⁹. Neolithic shamans of mankind’s earliest societies

(A trepanned skull, the earliest evidence of medical intervention. Source: https://upload.wikimedia.org/wikipedia/commons/thumb/5/52/Crane-trepanation-img_0507_crop.jpg/1024px-Crane-trepanation-img_0507_crop.jpg)

would drill into the skull until the white matter of the brain was visible to the naked eye, with the belief the surgery would release evil spirits afflicting the sick⁹. Today trepanning represents the first recorded instance of health intervention by fellow man, “medicine” in its simplest terms⁹. By no accounts is this rudimentary practice a form of dissection, but it serves as a beginning on the timeline of medicine that spans nearly nine millennia from the practice of trepanning to today. The first seven millennia of medicine practices were exclusively dictated by religious or tribal beliefs over any codified understanding of the human body, until approximately two thousand years ago when Aelius Galenus - or Galen as he is more commonly known - released his famous treatises, The Galenic Texts¹⁰. These sweeping volumes classified the human body as never before, mapping the muscle systems, identifying major organs and systemizing the four essential humors (black,
yellow, blood, and phlegm)¹⁰.

(A classical woodcutting describing the four humors. Source:

https://ridingingodssidecar.files.wordpress.com/2015/12/four-humors-granger.jpg)

Though antiquated by today’s standards, this compendium served as the primary medical text for more than fifteen hundred years, and the basis of nearly all Western medical practices in this time¹⁰. The classical practice of bloodletting for instance is directly derived from the humor model proposed by Galen, believing illness to be derived from an imbalance in the humors, thus excess blood was excised from the infirm member’s body as remedy. And yet, despite the text’s hallowed status, Galen never dissected a single human body – from the direct consternation of both Christian and Jewish churches considering the desecration of any human remains to be an excommunicable offense¹¹. Instead Galen completed his anatomical studies upon rhesus monkeys, relying upon their homological similarities to the human skeleton and muscular systems. Never dissecting a body in his time, Galen would never be aware of the inaccuracies between his animal work and the human physiology¹¹.

It wasn’t until 1543, that a Renaissance doctor by the name of Andreas Vesalius that dissection entered the modern medical practice – less than five hundred years ago, a blink in the near nine thousand years of medical practice. Vesalius, an established professor and surgeon of Padua began a series of lectures of live dissections for his disciples, performed on the bodies of deceased criminals, deemed by the church to be beyond reproach and fit for post-mortem examination¹². His findings were shocking, and often contradictory to the Galenic teachings that were so prominently disseminated at the time¹¹. For instance, Galenic text asserted that all blood vessels originated in the liver, as opposed to the heart¹¹. Vesalius would compile his work into his magnum opus, De Humani Corporis Fabrica Libri Septem¹². Over years of work in dissection, Vesalius and his pupils would compile one of the most extensive anatomical charts of the human body, each system expertly illustrated in his seven part book.

(An Andreas Vesalius illustration. Source: https://nyamcenterforhistory.files.wordpress.com/2014/10/vesalius_fabrica_1543_lambert_181_watermark.jpg)

The combination of precision in and fundamental reconstruction of the Galenic model, Vesalius’ work opened the doors for truly modern medical practices. With an accurate anatomy of the human body, the antiquated Galenic models were discarded and modern surgical practices quickly evolved under the newfound anatomical understanding¹¹. Surgeons could avoid arteries during amputations, and gallstones could be more easily pinpointed, the influence of an accurate anatomical topography was endless¹¹. Mixed with the fancy of the Roman Emperor Charles V, and the advent of the printing press, Vesalius’ work would travel like wildfire across Europe in even into Asia and North Africa¹².

 Despite the widespread popularity of De Humani Corporis, acceptance of dissection did not spread with the manuscript. In fact as the documents travelled across country borders, laws were enacted against the sourcing of human bodies for dissection. Several decades after the first publication, turnover within the Catholic Church led to more punitive measures against surgeons dissecting human remains for medical purposes than under the previous pope¹². And so as medicine advanced, developing doctors began illegally “body snatching” in order to practice anatomy and surgical techniques on a human specimen¹¹. Without a legal means in nearly every country, the banned practice remained in place consistently through the 20^th century. In the United States in particular, body snatching was common practice through the 1960s, until the Anatomical Donation Act was passed allowing for citizens to preemptively sign away their bodies to science¹³. Though no concrete statistics exist to quantify the extent of the illicit practice, the demand bodies across several thousand medical schools relative to the meager legal channels (dead federal prisoners) suggests a large percentage if not came from graves up to fifty years ago¹¹. 

Now after half a century of legal cadaver dissection we’ve begun to reverse the process of nearly nine thousand years in the making. Spearheaded by some of the United States’ top medical schools, there is a significant movement to altogether end the use of cadavers from the medical school curriculum. In 2011, Stanford University made wakes within the medical community introducing their ‘virtual dissection table,’ a backlight surgery table that illuminates human cross sections, and at a fingers touch can dissolve from cross section to cross section, progressing through the body¹⁴. An eminent figurehead of the medical school community, other schools in the San Francisco Bay area followed suit introducing similar virtual dissection tables to supplant a traditional cadaver lab¹⁵. A year later, St. Mary’s Hospital in London proudly became the first major European Hospital to incorporate virtual technology into their curriculum¹⁶. In a few short years, Stanford has halted all use of medical cadavers on its campus. And the epidemic is spreading quickly across the US and abroad as these once $300,000 tables are becoming more and more economical for smaller universities to afford¹⁵.

It is clear we are now in a transitory period in our use of cadaver labs, and it begs the question, “Are virtual dissections better?” While there are accessory interests, and financial incentives in moving towards a virtual lab, the absolutely essential product in question in the quality of doctor produced. That is a quality that no price tag can measure up to. And by this metric alone, the virtual dissection fails. Seldom does the word “never” appear in scientific literature, there is an inherent danger with speaking in absolutes. Yet in 2008 the ASME concluded this, “We recognize that virtual dissection will never provide the same hands-on experiences as physical dissection”¹⁷. And that is the core fault of virtual dissection exposed by an objective study. A physical, hands-on experience cannot be supplanted by clear cut virtual slides. “There is form of somatosensory learning that cannot be formed without physically engaging in the activity.”¹⁷. This fundamentally undermines perhaps the most important facet of a doctor’s education, their physical abilities, in a profession that is so inherently tactile. This isn’t to say that virtual reality models are not in some way useful. A recent study has shown that virtual reality models helps increase the ability for gastroenterologists to detect colon polyps at a significantly higher success rate than doctors operating without virtual reality training¹⁸. The distinction is this study uses virtual reality as a secondary method to augment medical practice over supplanting physical activity altogether¹⁷. Virtual dissections can make for an extremely useful tool to augment the learning of our young medical students, and even as a practice space for our most seasoned doctors, it simply cannot be used in place of the real body.

But the true impact of a course like gross anatomy is less so a matter of book education of dexterity, but as forge to temper the emotional maturity of our up and coming medical professionals. For forty-three years Dr. Snow, Ph.D has led the new medical students of USC Keck through their first human dissection, a process that begins with the back and slowly – over the course of a year – moves eventually to the face. He explains it’s a process adjusting to death, not in the way of accepting a grandparent’s passing, but accepting the death of a complete stranger – a sad but constant part of a job as a doctor¹⁵. And for the first class, the students simply acclimate to the chilled body locker. And while the image of forty or so bodies draped in sheets in a ghastly one to most, the student transformation by the end of the term is anything but. In the process of working with the bodies, which is on a near daily basis the students become incredibly close over the months they spend together¹⁵. They often name the cadavers (though they are never given their actual names for confidentiality), affectionately giving a personality to the man or woman that so generously donated their body for their benefit. Second year USC medical student Natalie Hartman best summarized her experience with her donor affectionately named ‘Admiral Victor,’ as such, “He was our first real patient. He was the first person to trust you with all of the insecurities and ailments of his body. And that’s a special connection.”¹⁹ In an industry founded upon doctor-patient relationships, this is an irreplaceable form of learning and maturation that cannot be forced or coerced on a virtual reality holodeck.

             So why are we still moving away from medical cadavers? In reality, the motive less a scientific one, but an emotional one more than nine thousand years in the making. The same cultural forces that opposed dissection during the time of Galen, and after the rise of Vesalius still echo today. Across regional and temporal lines, the resistance to medical dissection is distilled into a in a common theme: our relationship with death. There is something sacrosanct in the deceased that we all share, with no definite answers, nor explanation of what happens after death, we revere it, and we fear that which cannot fathom. Emotions and fervor trumped scientific and medical reason - it became easier to avoid the controversy by outlawing the practice than by permitting. Even today with the complete legality of medical cadaver sourcing, it still is a somewhat controversial topic, because of the uneasy nature of the subject, and that is something that simply is ingrained into our cultural perception of death. Other accessory arguments can be made toward the money spent sources bodies, and the difficulty there is in the process of acquiring donors. Likewise similar arguments can be made towards the whole digital movement of the medical industry as a whole. But as previously stated, the product is not measured in the dollars saved, but the quality of the doctor, and we cannot afford to short change our future doctors by taking the easy way out. Medical dissection like the Hippocratic Oath are not tradition within medical practice without good reason. They have been preserved over hundreds and thousands of years for their fundamental role in foundationally shaping the quality, expertise and above all caring that our doctors are expected to exemplify. It is just as much emotional as it is an intellectual commitment, and one experience we cannot let subside to the digital wake.

The final stanza of poem written by Warren Yamashita in memory of his cadaver perhaps best summarizes the lasting significance gross anatomy has on its subject:

“I promise, you are the first and last human being I will ever dehumanize.

I’m sorry for stabbing your heart, thank you for convicting mine.”²⁰

An editorial note from the writer:

I choose to begin not at medical cadavers, but with a note about heart surgery in the Seattle area. This wasn’t to hide my thesis pages deep into this article, but to provide some all too important context on the relationship of the digital world to medicine in this complicated issue. Had it not been for a surprise diagnosis in my junior year of high school, I might not be as aware as I am today. In 2011 I was diagnosed with a congenital heart defect that required surgery. In the terrifying process of preparing for heart surgery I was able to witness the effect that these new technological leaps in cardiology – and leap is an understatement – that have been made in the last several years. The surgery I opted, a minimally invasive catheter ablation for had a 92% survival rate at the Seattle Children’s hospital. Had surgery become necessary two or three years earlier, before the necessary laparoscopic camera had been developed, the open heart conditions would have dropped by survival rate to about the flip of a coin.

With an issue like medical cadavers that is a complicated nexus of so many conflicting perspectives, it’s an issue that can quickly become obfuscated with one voice or one viewpoint too strongly represented. Within this argument there is a very serious case to be made towards the preservation of cadaveric dissections, and non-digital methods, especially in consideration of the quality of the doctors we are producing. In many respects this is an issue much less about survival rates, but on the cultural relationship we have with death, and for good reason we as a culture are weary of cutting up our fellow man. This traditionalist view of medical cadavers that I want to avoid from blinding the larger issue at play: that is the ever increasing relationship of medicine and digital technology. For all the ardent support I will put towards the continuation of medical dissection, I cannot ignore the profound and important impact emerging digital technologies, for me, my very life, my family, my hometown of Seattle, and the global community at large.

In a world with so many changing parts, from changing presidencies to changing gas prices, we have a habit of comparing then to now; past to present. While we’ve made so many fundamental strides within medicine, we can’t ignore what has worked in the past to favor a new trend the present, simply because of a false dichotomy we’ve created between old and new. New has its place, be it catheter heart surgery or PET scans, but cadaver dissection has persisted through centuries of hardship and illegality, and not without good reason. Young doctors need the experience; it’s something indelible that simply cannot be faked. Gross anatomy is just as much a part of the Renaissance age of Vesalius as it is now at the USC Keck School of Medicine, Fall Semester 2016. 

End Notes:

¹Minimally Invasive Heart Surgery. (2016). Mayo Clinic. May Clinic Tests and Procedures.           Retrieved from: heart medicine: http://www.mayoclinic.org/tests-procedures/minimally-         invasive-heart-surgery/basics/definition/prc-20013701

²Minimally Invasive Heart Surgery. (2009). Brown University. Department of Biomedical Sciences. Retrieved from:   http://biomed.brown.edu/Courses/BI108/BI108_2000_Groups/Heart_Surgery/

³Komo News: Seattle. Seattle Hospital Ranks Among Best for Heart Surgeries. Retrieved from:

            http://komonews.com/news/healthworks/seattle-hospital-ranks-among-best-for-heart-         surgeries

⁴Topol, K. (2012). The Creative Destruction of Medicine: How the Digital Revolution will Create Better Health Care. New York: Knopf. Retrieved from:     https://books.google.com/books?hl=en&lr=&id=I6Bgje2T7Q8C&oi=fnd&pg=PT5&dq=            digital+medicine&ots=ipXFUf8giY&sig=9adCD74kWSulgrnUFB5xHeswuOk#v=onepa            ge&q=digital%20medicine&f=false

⁵Shaffer, D. (2002). What is Digital Medicine? Stud Health Technol Inform. 2002; 80; 195-204.   Retrieved from: https://www.ncbi.nlm.nih.gov/pubmed/12026129

⁶Elenko, E. (2015). Defining Digital Medicine. Nature Biotechnology. 33, 456–461 (2015)             doi:10.1038/nbt.3222. Retrieved from             http://www.nature.com/nbt/journal/v33/n5/nbt.3222/metrics/index.html

⁷Terhune, C. (2009). The Dubious Promise of Digital Medicine. Business Week. April 2009.         Retrieved from: http://securehealth.freshdefense.net/content/dubious.pdf

⁸Reidenberg, J. (2002). The new face of gross anatomy. The Anatomical Record.   doi/10.1002/ar.10076/full

            http://onlinelibrary.wiley.com/doi/10.1002/ar.10076/full

⁹Arnott, R., ed. (2013). Trepanation. New York: Puffin Books. Retrieved from:             https://books.google.com/books?hl=en&lr=&id=wisNNoceOzoC&oi=fnd&pg=PA223&dq=trepa            nation&ots=NbFJWw89j5&sig=A_RvIu2sJr3VqKEhSwQJ_Ca49YA#v=onepage&q=trepanation            &f=false

¹⁰Galen of Pergamum. Encyclopedia Britannica Online. Retrieved from:             https://www.britannica.com/biography/Galen-of-Pergamum

¹¹M. Rosenbloom, Interview, September 6^th, 2015.

¹²Andreas Vesalius. Encyclopedia Britannica Online. Retrieved from:

            https://www.britannica.com/biography/Andreas-Vesalius

¹³University of Arkansas. (2010). Gross Anatomy: Then and Now. College of Medicine History.   Retrieved from:  http://medicine.uams.edu/about-the-college/college-of-medicine-history/history-      features/gross-            anatomy-then-and-now/

¹⁴Stanford University. (2011). Body image: Computerized table lets students do virtual dissection.             Stanford Medicine. Retrieved from: https://med.stanford.edu/news/all-news/2011/05/body-image-            computerized-table-lets-students-do-virtual-dissection.html

¹⁵M. Snow. Interview. September 5^th, 2015.

¹⁶BBC. (2012). Virtual surgery: How to dissect a digital cadaver. Retrieved from:             http://www.bbc.com/news/technology-18173263

¹⁷McKenna, A. (2008). The American Society of Mechanical Engineers. Paper No. DETC2008-49783, pp.             359-368; 10 pages  doi:10.1115/DETC2008-49783

            http://proceedings.asmedigitalcollection.asme.org/proceeding.aspx?articleid=1628828

 ¹⁸Hock, D. (2007). Virtual Dissection CT Colonography: Evaluation of Learning Curves and Reading             Times with and without Computer-aided Detection. RSNA Radiology. DOI:             http://dx.doi.org/10.1148/radiol.2482070895. Retrieved from:             http://pubs.rsna.org/doi/abs/10.1148/radiol.2482070895

¹⁹N. Hartman. Interview. September 4^th, 2015.

²⁰ W. Yamashita. Personal Correspondence. September 11^th, 2015.