Anatomy is to physiology, as geography to history; it describes the theatre of events.
– Jean-Fernel, On the Natural Part of Medicine (1542); cited in C. Sherrington, The Endeavour of John Fernel (Cambridge: Cambridge University Press, 1946), 64
Anatomy is the study of the structure of the body. Today it seems integral to the study of medicine, but structural explanations of disease were long considered secondary to those of function (physiology). This chapter will explore the rise of anatomy from irrelevancy – even taboo – to its place as an institutional power in medical education.
The word ‘anatomy’ is derived from the Greek word anatome, meaning dissection. It still implies cutting, but also structure (morphology) – the shape, size, and relationships of body parts. It is also a metaphor for the analysis of any problem.
Medicine is the study of disease and its treatments. To understand disease, doctors focus on abnormalities of structure and function which are the objects of the complementary disciplines of anatomy and physiology. Traditionally, these two domains have competed for curriculum time, laboratory space, and pride of place in the minds of practitioners..Of course, considerable overlap takes place between structure and function: a broken leg does not work very well; neither does a heart with a hole in its septum. But abnormal structure does not always imply disease; for example, congenital deformities, such as having six toes or a large birthmark, are not intrinsically associated with suffering or shortened life. Similarly, abnormal function can be compatible with healthy living; for example, the carrier states of the hereditary conditions of thalassemia or sickle-cell disease are detectable, but they convey few consequences for affected individuals.
Medical cultures that emphasized the study of anatomy peaked centuries ago, in Alexandria, then declined, peaked again during the Renaissance, then declined, and peaked again in the last century. The present form of medical education still reflects this most recent heyday, but the perceived centrality of anatomy in modern medicine may be on the wane again.
Three themes recur throughout the history of anatomy:
- Ambivalence, or ‘approach-avoidance.’ Should anatomical dissection be allowed or not? The desire to learn about illness often conflicted with religious or cultural aversions to the notion of cutting up dead bodies.
- ‘The gift of art to medicine.’ The expression of anatomical wisdom relied on visual forms of communication.
- Anatomical study separate from medical wisdom. The pursuit of anatomy in art or science did not imply equal status in medicine.
Dissection and Anatomical Ideas in Antiquity
The elaborate burial practices of the ancient Egyptians provided frequent opportunities for the observation of body parts. Embalmers were adept at situating and extracting organs through tiny holes and slits in the body. Egyptian graphic art may have been stylized, but the statuary reveals a sensitive appreciation of surface and underlying structures. Unlike the embalmers and artists, however, the physicians do not appear to have used anatomy.
Our knowledge of ancient Egyptian medicine is based on a few surgical papyri (see chapter 10). Egyptian explanations of disease seem to have emphasized physiology, in which breath was the essence of life. Blood vessels were hypothesized rather than known, and only a few organs were connected with specific functions. Some organs were associated with certain deities and used as hieroglyphics. For instance, a stylized uterus, or sa, represented the goddess of childbirth. Because this symbol was bicornuate (had two horns), scholars think that the model may have been animal rather than human. The heart symbolized the soul. In illustrations for the Book of the Dead, the heart of the deceased is weighed against the feather of truth; when the two balance, the soul may pass on to the next world (see figure 2.1).
Ancient Greek sculpture reflects a preoccupation with the accurate portrayal of surface anatomy, with attention to the underlying muscles and bones. Votive offerings left at temples by sick people hoping for cures were fashioned from clay or stone to resemble afflicted body parts – uterus, breasts, bladder, and limbs – sometimes with anatomical derangements such as varicose veins.
Despite these artistic influences and their skill in observation, Greek doctors were not especially interested in anatomy. Dissection of human bodies was forbidden, and funeral practices centred on cremation. Function was more important than structure. Explanation of illness relied on the four elements (earth, air, fire, and water) and their four cognate humours inside the body (see chapter 3). Given the laws and funeral customs, few opportunities arose for examination of internal structures of humans. Exceptions are found in Hippocratic treatises on fractures and dislocations, which reveal extensive knowledge of bones and joints.
Illustration is essential to the teaching of anatomy, and the ban on dissection did not extend to animals. The fourth-century B.C. philosopher and biologist Aristotle appears to have used large diagrams when he taught the comparative anatomy of animals. Unfortunately none of the original drawings has survived.
After about 300 B.C., the city of Alexandria permitted dissection of the bodies of criminals, alive or dead. These public demonstrations were designed to horrify as much as instruct. That the practice was reserved for criminals indicates the social ambivalence regarding dissection, which could be seen as a desecration. Two Alexandrians, Herophilus and Erasistratus, described minute structures, including lymph lacteals, the meninges, and vascular structures such as the torcular herophili (named after Herophilus). Like the: early illustrations, none of their writings has survived. Our evidence for their work is based on other writers, including Galen, who lived some four hundred years later.
Galen on Herophilus
Herophilus ‘attained the highest degree of accuracy in things which became known by dissection, and he obtained the greater part of his knowledge, not like the majority … from irrational animals, but from human beings themselves.’
– Galen, second century A.D.; cited in H. von Staden,
Herophilus (Cambridge University Press, 1989), 143
Galen was born in 129 A.D. in Pergamum, on the Aegean coast of modern Turkey, but he lived much of his life in Rome. He deplored the laws that forbade human dissection; at least three of his many treatises were devoted to human anatomy, ostensibly as understood by the Alexandrians. Galen served as a physician to the gladiators, and he may have taken advantage of gaping wounds to observe internal structures. A great experimenter, he dissected animals, both living and dead, his preferred subjects being the pig and the monkey. He extrapolated from animals to humans and devised elaborate theories concerning anatomical structures, the motion of blood, and the origin and sustenance of life. Some observations were accurate for animals but missed their mark when applied to humans; for example, he ascribed five lobes to the liver and a vascular network in the brain called the rete mirabile.
Galen’s writings are authoritative and bragging, and his teleological perspective allowed him to conceive of all structures as having been created for a purpose (see chapter 3). This confident philosophy corresponded well with the views of Christianity. As a result, his writings were the medical texts of choice for more than a thousand years. His immediate successors may have carried out some human dissection, but anatomies became rare and ritualized exercises for endorsing Galen’s authority, not for seeking truth.
An anatomy lesson is the subject of a fourth-century A.D. wall painting from a Roman catacomb (Via Latina), discovered in 1957. The instructor sits a considerable distance from the cadaver. Neither he nor his students touches the body, which is prodded with a long pole as it lies on the ground as if to emphasize its base nature.
The oldest extant anatomical illustrations date from the early Middle Ages and are the work of Persian and Arab scholars, who preserved and transmitted the ancient Greek authors, illuminating the texts with stylized diagrams. The schematic figures squat in a froglike posture to expose the genitalia and the inner aspects of the limbs. Several drawings usually complete each series of five or six systems: vessels, muscles, nerves, organs, and bones (see figure 2.2). The practice extended into medieval Europe. The German medical historian Karl Sudhoff, who made a study of these drawings, concluded that their Greek precursors in Aristotle’s work had probably come in similar series of five or six.
Medieval Treatises on the Body
In the thirteenth and fourteenth centuries, art and anatomy both experienced an awakening, fostered by legislative changes, the decline of religious teaching, and reactions to criminal violence or epidemic diseases. Municipalities, especially in Italy, were pressured to permit dissection in order to determine cause of death in cases of murder or other unusual situations (see table 2.1, page 18).
The rise of secular universities also contributed to the increase of dissection. In Christian tradition, the body was linked to sin and the temporal existence of the profane world. Learning about its inner workings was not only unnecessary but it could jeopardize salvation, because the literal interpretation of Scripture anticipated the resurrection of the soul within an intact body. As a result, the church did not condone dissection. Images of anatomies from the medieval period emphasize the barbarity of the act. Sometimes, the pope, granted, special dispensations for certain medical schools, such as Montpellier in southern France, but the subjects were executed criminals – or, on rare occasions, living criminals, who may have been sentenced to death by vivisection. Tension grew as schools yearned to practise dissection and the church refused; the resultant disorganization mirrored inconsistencies in the evolving power structure of society. Would-be anatomists were sometimes prosecuted.
Legal dissections were ritualized and infrequent – once or twice a year, for example; in some places, only once every five years. The professor sat high above the scene, reading from a Latin edition of Galen. The demonstrators were often illiterate barbers, who dissected in conjunction with the lesson. (On barber-surgeons, see chapter 10.) As a result, the words of Galen could persist unchallenged. Differences between the cadaver and a Galenic ideal were explained by the imperfection of the (usually criminal) mortal (see figure 2.3).
One anatomist who broke with tradition was the Italian, Mondino dei Luzzi. He emphasized the need for anatomists to do their own dissection: but his teachings differed little from Galen. His 1316 treatise, the Anathomia Mondini, became the standard reference for the next 150 years. Its manuscript editions were not illustrated, but later versions were; however, when his work was first printed in 1478, it was already being superseded by newer treatises.
The artistic awakening of the late Middle Ages was applied to the portrayal of the body in several fourteenth-century anatomical treatises. In the Chirurgia (Surgery) of Henri de Mondeville, the image of the patient/cadaver is vertical and slightly more fluid than its rigid predecessors, as if captured in living action (see also chapter 10). The numerous images in the 1345 treatise of Guido de Vigevano (actually an illustrated edition of Mondino) display the anatomist himself conducting the dissection; however, the stylistic portrayal recalls the five-figure drawings from centuries before.
Sometimes the image of a ‘zodiac man’ was used to explain the relationship between the body and the external world and to indicate the auspicious times and sites to treat. These figures synthesized a large amount of information. Modifications were made to illustrate many potential injuries or diseases with the appropriate sites and methods of treatment: a ‘wounds man,’ a ‘disease man,’ and a bloodletting man. Examples of these ‘men’ are found in the treatise Fasciculus medicinae (ca 1491)by Johannes de Ketham (see figures 2.4 and 2.5). Despite its apparent artistic and intellectual conservatism, the Fasciculus relied on one important innovation: printing. It could be said to mark a symbolic beginning of the anatomical Renaissance.
Art and Renaissance Anatomy
The Renaissance is a period in Western European history – roughly from 1400 to 1600 – when an artistic and intellectual awakening coincided with a reappreciation of the ancients. Many causes – economic, social, and demographic – can be cited for the Renaissance. From the perspective of medical history, one of the most intriguing and debated ’causes’ is the fourteenth-century plague, which depopulated Europe and radically altered its economic structure (see chapter 7). Plague endorsed a certain scepticism toward Galen, who had not described it, and toward the church, because the ‘good’ seemed to die as readily as the ‘sinful.’ It also affected art. People became inured to the spectacle of corpses in the street, and the horror of human remains tended to fade. Prominent citizens took to having themselves portrayed on their future tombs as rotting corpses memento mori – gruesome anatomical reminders of death, which not even the church could challenge. With this revival, or rebirth (renaissance), came a reappreciation of classical authors, art, and language, and a rediscovery of the beauty of the human body and the various modes of portraying it. If the exterior of the body could be glorified, it was a simple matter to extrapolate attention to its interior.
Renaissance art contributed to anatomy, and artists conducted dissections. For example, Leonardo da Vinci – architect, painter, engineer, scientist, and philosopher – claimed to have dissected thirty bodies himself, although scholars now think it was fewer than ten. He planned a treatise of anatomy, maintaining that to elucidate the structure of the human body, several ‘anatomies’ must be conducted – one devoted to each structural system: bones, muscles, vessels, nerves, and organs. Two hundred pages of Leonardo’s anatomical sketches and writings are kept in the Royal Library at Windsor Castle, England. His famous ‘Vitruvian man’ was drawn in the same year as the printing of Ketham’s more static figures; the contrast between them demonstrates that anatomical detail preoccupied artists more than physicians.
Leonardo was interested in the finer points of structure for scientific and artistic reasons, but contemporary medicine remained ignorant or uninterested, and doctors continued to recite Galen as told by Mondino. Thirty years after Leonardo’s drawings, yet another commentary on Mondino was published, by Giacomo Berengario da Carpi, who provided pleasing but stylistically simple woodcut images of cadavers, sometimes in the lifelike act of helping out with the dissection.
Why were medical practitioners less interested in anatomical wisdom than they are now? Doctors treated the sick for subjective illness, suffering, and dysfunction, but except for fractures and dislocations, most alterations in structure were impossible to fix. Consequently, trying to correlate disease with dead internal organs, which could be neither visualized nor altered during life, seemed to be a waste of time (see chapter 4). Clinicians did not reject dissection as an intellectual pursuit, so much as they found it lacking in practical application.
Vesalius and the Fabrica (The Structure of the Human Body)
The magnificent De humani corporis fabrica of Andreas Vesalius was published in 1543, fifty years after Leonardo’s drawings. Born in Brussels in 1514, Vesalius studied medicine at Louvain, in modern-day Belgium, before travelling to France. In Paris he was taught by a professor who read Renaissance-style from Galen while prosectors dissected below. Vesalius later claimed to have dissected, boiled, and reassembled his first skeleton from the corpse of an executed criminal stolen from a gibbet. He moved on to Padua near Venice, where anatomy was more deeply integrated into medical studies than in Paris. Shortly after his arrival, he was awarded a doctorate in medicine. The following day, according to an oft-repeated legend, he was appointed ‘professor’ of surgery at the age of twenty-three. Vesalius then began anatomical teaching in earnest.
Not only did Vesalius conduct his own dissections, but he befriended artists of the nearby city states in Venice and Florence. Scholars have suggested that the contact was fostered by apothecary shops, where doctors went for their medicines and artists bought their pigments. Consequently, Vesalius obtained advice from talented artists, and therein lay his success.
In 1538 Vesalius published his first book, a sort of hors d’oeuvre that preceded his chef d’oeuvre by five years. Called the Tabulae sex (Six tables), this short book was astonishingly popular because it was illustrated with high-quality images. In keeping with long-standing tradition, it contained only six illustrations with narrative; reflecting Renaissance ideals, three ancient languages were used: Latin, Greek, and Hebrew. Despite the evident care taken in artistic preparation, some morphologic features and body proportions seem not quite right; the spine is a little too straight, the ribs shortened. More surprising are the residual Galenic features: a five-lobed liver and the rete mirabile! Surely, after all his personal experience, the young Vesalius knew that these structures did not exist. Why did he leave them there? Some historians think that it was a deliberate attempt to soften the reaction to his future work and spare himself the hostility of his older colleagues. The Tabulae sex sold out rapidly and was ‘read to bits’ as students hung the large images above their dissecting tables. Copies of the Tabulae are more scarce than original editions of the much bigger and more famous Fabrica.
On the title page of the 1543 Fabrica, Vesalius shows himself surrounded by a huge crowd at the Padua faculty; he is looking boldly at the reader while he dissects the corpse of a woman. The cadaver, he tells us, was the mistress of a monk; he and his students had acted quickly to remove identifying features before the body could be taken by the grieving cleric. The page is full of symbolism. Below are the barbers, displaced from the table and squabbling. Cast off to the side are animals – dogs and monkeys, Galen’s subjects and the source of his errors. Above, in the traditional place reserved for the recitation of Galen, is a skeleton. In the crowd are Vesalius’s students and colleagues, including ancient savants, the bearded Realdo Colombo, who described the pulmonary circulation, and a youth writing or drawing, who, some think, may be the artist. Despite the emphasis on innovation, historian Andrew Cunningham has drawn attention to Vesalius’s connections with the anatomists of antiquity; he found impressive clues, not only on the title page, that the anatomist was actually ’emulating’ Galen. By his method, with its emphasis on personal exploration and vivisection, and despite his refutation of some Galenic anatomy, Vesalius ‘was simply Galen restored to life,’ a true Renaissance man (Cunningham 1997, 114). He also reminds us how early modern dissection continued to have ritualistic significance.
“Who was Vesalius’s artist? Similarities in the Mannerist style with the landscape background and architectural elements lead some to claim that it was the great Titian. The most likely candidate, according to a letter by Vesalius, is his fellow Belgian, Jan Stefan van Kalkar, who worked in Titian’s studios. Another meticulous craftsman was probably engaged to sculpt the wood blocks from the original drawings. The blocks were then carried across the Alps for printing by the leading house of Johannes Oporinus in Basel, Switzerland.
The Fabrica contained not six drawings but seven books of many drawings each. The first book was devoted to the skeleton. The second featured the muscle men, the most famous series in the treatise, beginning with eight poses in the front view, including the écorché, a body with only the skin removed (see figure 2.6). Commentary explained what had been done to create each successive image by cutting the muscles at their origins to leave them dangling by their insertions. Ironic humour pervades the artwork: as the layers of muscle are removed, the poor cadaver became the worse for wear, moving from athletic exuberance to needing ropes and walls for support. The anatomical decay is reflected in the landscape background, which becomes increasingly barren as summer turns to winter. After the eighth pose, the whole process is repeated for the back view of the body.
The third book was devoted to the veins and arteries – gone was the rete mirabile of 1538. The fourth book described the nerves. The fifth explored the abdominal organs, with the liver’s lobes reduced to two. It also included dissections of the genitalia, which have become the object of scholarly curiosity. The vulva, vagina, and uterus of the monk’s defunct mistress are shown without adnexal attachments; the image resembles a penis, inviting speculation about a message of homology (see figure 2.7). The sixth book focused on the thoracic organs, and the seventh, on the brain.
Some anatomical inaccuracies can be identified in these images; for example, the rectus abdominus muscle extends too far up the rib cage. In contrast to its predecessors and many of its successors, however, Vesalius’s achievement was unequalled. The Fabrica has become an object of veneration; first editions have been tracked down, and new translations made. Terence Cavanagh showed that placing the reversed muscle figures in a series creates a continuous landscape. Some scholars locate the scenery in the Eugenean Hills near Padua, where scores of doctors have travelled in search of the exact site.
Vesalius soon gave up academic life, and he successively went into the private service of various crowned heads: the Holy Roman Emperor Charles V, Philip II of Spain, and Henri II of France. He then seems to have left royal service to travel, only to die while on a pilgrimage to the Holy Land. His unmarked grave is thought to be on the small Mediterranean island of Zante, but circumstances surrounding his demise are obscure. The carved woodblocks for the illustrations of the Fabrica survived into the’ twentieth century and were used for an edition in 1934. But during the Second World War, they were destroyed in the bombing of Munich.
After the Fabrica, scientists began to pay more attention to structure. Several similar works followed, each an artistic achievement in itself. A series of brilliant dissections resulted in the discovery of hitherto forgotten or unknown body parts. In 1545, Charles E[s]tienne published an atlas that gave special attention to nerves and vessels. In 1561 Gabriele Fallopio (or Fallopius) described the inner ear, the cranial nerves, and the fallopian tubes that had been missing in the Fabrica. Bartolomeo Eustachio (or Eustachius) demonstrated the adrenals, the vena cavae, the sympathetic ganglions, and the inner ear, including the tube that bears his name. Girolamo Fabrizio da Aquapendente (or Hieronymous Fabricius) described the valves of the veins in 1603, and twenty years later Gaspare Aselli found the lymph lacteals while dissecting a living animal that was in the process of digestion. In 1747 Bernard Siegfried Weiss (or Albinus) published his celebrated atlas, which featured engravings of muscled and unmuscled human skeletons in a lush forest with other exotic marvels, including a rhinoceros. Anatomical amphitheatres offered demonstrations to an eager and cultivated public.
Notwithstanding these accomplishments, anatomy still had little to do with bedside medicine. The sixteenth- and seventeenth-century anatomists concentrated mostly on the discovery and artistic portrayal of the normal, or healthy, human form. They did not relate structure to disease. But early in the seventeenth century, scientists began to apply the new knowledge about structure to the study of function. Physiology, rather than medicine, was the first to find applications for the new anatomical research. For example, William Harvey discovered the circulation of blood by relying heavily (but not exclusively) on his teacher Fabrizio’s demonstration of the valves in the veins (see chapter 3).
With the exceptions of Antonio Benivieni in the fifteenth century and Jean Fernel in the sixteenth, few writers were interested in abnormal anatomy until nearly a century and a half after the Fabrica. Théophile Bonet and Giovanni Battista Morgagni wrote massive compendia of anatomical pathology as a basis for disease; but their works were not illustrated (see chapter 4).
By the eighteenth century, dissection had become more respectable. A new philosophy of knowledge, called sensualism, was predicated on the view that all wisdom came from observation through the senses; observation was venerated, while theorizing was supposedly set aside. Anatomical studies could be seen to fit this new tradition. Artists painted distinguished anatomists at work surrounded by their students, ·a prime example being Rembrandt’s famous painting of the lesson of Dr Tulp. Others created wax models, which became an important tool of medical education. Museums were founded to preserve elegant dissections and waxes for future reference. Spectacular remainders are the eighteenth-century collections of John and William Hunter in London and Glasgow, of Honore Fragonard ·in Maisons Alfort outside Paris, of La Specola in Florence, and of the Mutter Museum in Philadelphia.
Observations in this early modern period sorted the body’s architecture into ever smaller organs and planes, relying mostly on the naked eye. Meticulous examinations laid the foundations of embryology and comparative anatomy. Consideration was given to what might constitute the elementary ‘unit’ of living beings, and for many years
Medical Mistrust of Anatomy
Others … have pompously and speciously prosecuted the promoting of this art by searching into the bowels of dead and living creatures, as well sound as diseased … but with how little success such endeavors have been or are likely to be attended I shall here in some measure make appear.
– Thomas Sydenham (ca 1668), cited in K. Dewhurst, Medical History 2 (1958): 3
All that anatomy can doe is only to shew us the gross and sensible parts of the body, or the vapid and dead juices all which, after the most diligent search, will be not much able to direct a physician how to cure a disease than how to make a man … If anatomy shew us neither the causes nor cures of most diseases I think it is not very likely to bring any great advantages for removeing the pains and maladys of mankind.
– John Locke (ca 1668), cited in K. Dewhurst, Medical History 2 (1958): 3-4
And over a century later …
Anatomy, though so carefully cultivated, has yet not supplied medicine with any truly important observations. One may scrupulously examine a corpse, yet the necessities on which life depends escape one … Anatomy may cure a sword wound, but will prove powerless when the invisible dart of a particular miasma has penetrated beneath our skin.
– Louis Sebastien Mercier, The Picture of Paris before and after the Revolution, 1788. Trans. Wilfrid and Emilie Jackson (London: Routledge, 1929), 97
fibre was championed by careful observers, such as Giorgio Baglivi. A theory of tissues, rather than organs or fibres, began in the late eighteenth century, and continued with the advent of microscopy – an example of the reciprocal promotion of ideas and technology (see chapter 9). The notion of cells as the fundamental unit, often ascribed to Robert Hooke, did not emerge as a theory until much later with the work of Germans – zoologist Theodor Schwann, botanist Matthias Schleiden, and pathologist Rudolf Virchow. Cell theory found worthy opponents such as T.H. Huxley, whose heavy criticisms of 1853 are said to have done more to spread the idea in Britain than to defeat it. Again, knowledge and microscopic technology were mutually reinforcing; use of the microscope alone did not establish the theory; first cells had to be imagined, or ‘envisaged.’
Despite these scientific successes, anatomy’s relevance to medicine continued to be ill-defined. Why? First, aversion to human remains persisted. Eighteenth-century caricaturists such as William Hogarth derided dissection as a vile act, an appropriate ‘reward for cruelty’ (see figure 2.8) Second, even doctors who practised anatomy had difficulty imagining how to apply it; the same sensualism that celebrated anatomy made it an object of suspicion when it came to medicine. Doctors could not diagnose internal changes until the patient was dead; nor could they correct them. Diseases and diagnosis were based on symptoms (see chapter 4).
Anatomy Goes Medical
At the beginning of the nineteenth century, technology and a reconfiguration of disease concepts changed medical attitudes to anatomy. The diagnostic techniques of percussion and auscultation made it possible to detect structural changes inside the chest. Names and concepts of diseases changed from being subjective symptoms, such as hemoptysis and shortness of breath, to associated anatomical lesions, such as pulmonary effusion, pulmonary consolidation, and emphysema (see chapters 4 and 9).
As diseases became increasingly anatomical, medicine had to move in the same direction. Anatomy and dissection suddenly became not only interesting but essential for medical training. Chairs of anatomy, which had once been independent, became a feature of every well-dressed
medical school. Pathological anatomy soon followed: the first British chair of pathological anatomy was awarded to Robert Carswell in 1828; the first French professorship went to Jean Cruveilhier in 1835. By 1848, twenty-five of the approximately forty medical schools in the United States offered instruction in dissection.
New problems soon arose because of the limited supply of bodies. Dissection may have become acceptable to academics, but the general public was not eager to see the corpses of its loved ones opened and displayed for instruction. Few places enjoyed legal mechanisms for obtaining anatomic material. In cities with large poorhouses and public hospitals, such as post-revolutionary Paris and New Orleans, unclaimed bodies were automatically given to medical educators. Elsewhere, cadavers were retrieved from cemeteries or were purchased on the sly.
The new occupation of ‘resurrection man’ emerged. Fabled in song and story, it satisfied the growing market for fresh bodies with the newly buried corpses of private citizens. Cages of iron, called ‘mortsafes’ were invented to protect wealthy corpses from body snatchers. The public was offended by the outrageous practice, and turned on the grave robbers’ clients too. In the United States, physicians’ homes and medical schools were mobbed and burned on several occasions. Cemeteries were guarded; following a burial, wealthy citizens posted sentries to protect family plots from violation. The Canadian medical teacher John Rolph, temporarily in exile at Rochester, New York, for his part in the 1837 Rebellion, had a former student in Toronto ship anatomical subjects across Lake Ontario in whisky barrels. To avoid middleman costs, medical students became adept at grave robbing; those in Kingston, Ontario, were notorious despoilers of patrician plots. Where medical schools operated in proximity to graveyards, the trade in human bodies could be brisk and ruthlessly competitive.
The inevitable happened: murder for the sale of corpses. Unknown numbers of disadvantaged people may have been killed to this end. Students and professors might have guessed the provenance of especially fresh or healthy-looking cadavers; however, in their eagerness both to dissect and to maintain supplies, they asked no questions. In the famous case of 1823, the Scotsmen William Burke and William Hare murdered at least sixteen people and sold the corpses to Robert Knox, anatomist at the leading medical school in Edinburgh. Knox took pains to remove the heads and other identifying features from the bodies as soon as he received them. First, the pair preyed on the poverty-stricken elderly tenants in Burke’s home. Then they murdered a local prostitute, well known to the students; but the lads merrily dissected her corpse without comment. Only when Burke and Hare kidnapped a well-known boy with mental retardation, James Wilson (‘Daft Jamie’), was suspicion aroused. A few days later, the body of Margery Docherty, a healthy woman who had been reported missing, was found in the anatomist’s laboratory. Burke and Hare were charged with her murder. Hare was excused by testifying against his accomplice. Burke was hanged, his body dissected in public, and the remains displayed for hundreds of onlookers. His fate indicated that dissection was still a ghastly ‘reward for cruelty’; his name is a synonym for murder. Neither Knox nor his students were charged, but the professor’s career was in ruins.
Soon after, legislation restricted the sale of bodies and provided medical schools with access to unclaimed corpses in hospitals, prisons, and poorhouses (see table 2.2). France and Germany and other places in Europe had enacted legislation in the late eighteenth century. In Britain, the Anatomy Act became law nine years after the Burke and Hare affair. Massachusetts also moved early in this regard, but most American states revealed their chronic ambivalence to the issue by failing to pass legislation until after the Civil War. Canada’s anatomy legislation was the special project of the colourful physician pioneer William ‘Tiger’ Dunlop. Recent scholarship examines the complexities of obtaining cadavers for medical education in Asian countries, when the advent of Western medicine appeared to conflict with cultural and religious practices. In Japan, it was only after the expansion of Western-type medical schools in the 1970s that donation became acceptable; a law was passed in 1983.
Dissection slowly became acceptable to the public. Scenes of anatomy lessons relinquished their ghoulishness for an aura of solemnity, which symbolized the seriousness of medicine itself. Improved techniques of preservation and injection of blood vessels enhanced the longevity and utility of each corpse. Gender became an issue as women entered medicine in the late nineteenth century. Many schools believed that ladies were too delicate to confront corpses or to look on naked male bodies, especially in the presence of living men, and some schools exempted women from dissection or stipulated that they take their classes separately. Problems with the supply of cadaveric material remained. The anatomy laws applied most often to those disadvantaged by poverty or race. The idea of donating one’s body to science had yet to take hold, especially when medical students were fond of joking about cadavers and skeletons and had themselves photographed with the specimens in disrespectful poses (see figure 2.9). During the Third Reich, the corpses of thousands of murdered Jews were sent to medical schools to satisfy the ostensible need for teaching and display. In 1998, investigations revealed that at least 1,377 bodies had been sent from Nazi death camps to Vienna, where the professor Eduard Pernkopf used them in preparing his sophisticated and widely used anatomical atlas. Anatomists, historians, librarians, and ethicists still debate the appropriate uses and continued existence of this controversial book.
But gradually the stigma was removed, and people became willing to leave their bodies to science, in a new form of socially acceptable charity. In the latter decades of the twentieth century, with the added possibility of organ transplantation, donation was actively promoted by governments and the general public. Historians have examined this new impulse of fleshly gift giving as an indicator of attitudes to science, education, and death. Most schools now mark the donation with an annual service of thanksgiving and respect. At our medical school, a special plot is kept for the remains in the local cemetery
Anatomy Today: Basic Science or Hazing Ritual?
When health-care practitioners look back on the past that has just been described, it is difficult for them to see it as anything other than a logical series of progressive steps leading to openness and tolerance about the body that is the essence of medical wisdom and practice. For them, the body is a neutral and obvious assemblage of structural ‘facts,’ which should be available to all. Recently, cultural historians have shown that the story is not quite so straightforward. In a new trend called ‘body history,’ they challenge the idea of the human form as an immutable entity that is simply waiting to be discovered and explored. They have shown how its ‘construction’ was influenced by social and cultural pressures of time and place (see chapter 4). Instead of tracing a story about the ‘fabric’ of the body, historians are interested in how it may have been ‘fabricated.’
For example, Londa Schiebinger pointed out that the shapes imputed by eighteenth-century anatomists to the female pelvis exaggerated natural proportions in a manner that emphasized women’s role in childbearing. Similarly, Thomas Laqueur examined structural representations of femaleness as vehicles for the expression of political and cultural attitudes toward women. Sander Gilman and John Efron showed how anti-Semitism contributed to the ‘normal’ but deviant anatomies of Jews. Concepts of normalcy are culturally contingent; for example, excess weight can be a manifestation of health in one culture and a sign of illness in another. Other ideals of size and proportion, including height, skull capacity, and brain size, also have been influenced by notions of racial, cultural, and gender superiority. David Armstrong has shown that the constructing influences now include anatomy itself, which has become so pervasive in medical thought that many immaterial problems, such as illnesses, are reified as if they were material entities (see chapter 4). These ideas often spark opposition from anatomists who believe that they go too far.
If the history of anatomy is no longer quite as obvious as it once was, its future seems equally in doubt. Where exactly is anatomy going? Is it a pillar in the institutions of learning or has its time passed? Are we witnessing a new rise in the relative significance of function over structure? Mounting evidence suggests that anatomy as an investigative discipline may be in decline once again.
After the hard-won legacy of Mondino and Vesalius, it is surprising that medical students rarely do their own dissecting. Demonstrators or prosectors prepare specimens in advance. Some demonstrators are surgical residents who need refresher courses, because their anatomy has been forgotten in the subsequent training. Why? Because detailed anatomy is not reinforced by the general practice of medicine. In acknowledgment of this reality, the innovative schools at McMaster University in Hamilton and at Calgary (founded in the late 1960s) have never taught anatomy through formal dissections.
Anatomy continues to hold departmental status in many health science faculties; however, it has difficulty claiming to be a discrete research discipline. Questions of morphology address ever smaller components of the cell, and its molecules, often making it difficult to distinguish anatomy from physiology. The publications of anatomy professors rarely address the elucidation of gross or even microscopic structure. At best, they investigate ultrastructure, growth, and function of embryos, cells, and genes. Often their research bears little connection to anatomy at all. Department names are being changed to include the words ‘cell biology,’ while the seemingly old-fashioned museums are dubbed ‘learning centres.’ Cadavers are being replaced by electronic models, accessible on the Internet or CD-ROM. One example is the Visible Human Project, sponsored since 1986 by the National Library of Medicine.
These observations are not meant to imply that study of body structure is irrelevant to medical practice or that it does not deserve a prominent place early in medical training. On the contrary, illness is felt and diagnosed within the body. But we can ask why anatomy continues as a form of academic organization if it is no longer a field of active research. The once-shunned discipline is now establishment. Even as the hours devoted to the study of anatomy are shrinking, the long-contested privilege to dissect is not relinquished easily. Some teachers lament its passing, pointing to the sensory and professional advantages of handling a cadaver; our teachers dissected, we dissect, and our students must dissect too.
Moreover – and in striking contrast to the past – society now expects future doctors to cut up dead bodies, even when they do not. While continuing to condone the practice, awestruck relatives and friends betray traces of retained revulsion when they ask medical students for the gory details: ‘Ooooo! What’s it like?’ The same mix of fascination and horror greets the ‘Body World’ exhibitions of corpses plastinated by Gunther von Hagens; he claims to oppose elitism, hoping to demystify the body in health and disease and to educate through aesthetics. However, his grand public displays – sometimes called ‘edutainment’ – emerge from a tradition that stretches back to Vesalius and continues to provoke ethical comment. Are the poses disrespectful? Should anyone other than scientists gaze at the flayed dead?
Anatomy distinguishes doctors from others; it demarcates modern medicine, both intellectually and socially. Aside from its many other intrinsic merits, the study of anatomy is a symbolic rite of initiation that socializes members into a professional tradition.
1. Recently, there has been some debate among Canadian medical schools as to the relevance of including student-performed dissections in the medical curriculum. Where do you see the future of anatomy and student-performed dissections going in our medical schools?
2. What fact about the history of anatomy surprises you most in this article? How, if at all, does knowing about the history of anatomy enrich our understanding of it?