Dissecting cadavers: learning anatomy or a rite of passage?
Hektoen International Journal is published by the Hektoen Institute of Medicine
2240 West Ogden Avenue, Chicago, IL. 60612
ISSN 2155-3017 - Copyright © 2009
Visit us at: www.hekint.org | www.hektoeninternational.org
Volume 1, Issue 5 - November 2009
Emmanuelle Godeau, MD, PhD
Service médical du Rectorat, Toulouse, France
In many medical schools, dissection of cadavers remains an essential component of the curriculum, even though surveys from the past 50 years have shown this is not the most efficient way of learning anatomy. Yet the persistence of dissections suggests a different role: a rite of passage and creating an esprit de corps for the profession. Our anthropological studies (1), in which one hundred medical students and doctors from France, Italy, Switzerland, and the United States were interviewed, support this thesis.
An ambiguous necessity
When medical students anticipate their first dissection, they vacillate between anxiety, boasting, fear, and excitement.1 This echoes the ambivalent memories of older doctors,2 who often reminisced that “one can’t see anything.” Many students and experienced doctors have questioned the utility of dissections. A student from Italy remarked, “The general impression was that it was pointless.” An American pathologist said: “Much of the traditional anatomy curriculum is irrelevant to medical practice and might easily be eliminated.”3 Still, all doctors recall those sessions, and generally associate them so strongly with “tradition” and “custom,” that not following them would pose the risk of never becoming a doctor: “I wanted to see, because one has to go and see,” or as an American student said, “Everyone correlates being a doctor with the study of anatomy” (2).
This necessity, vaguely felt by students and consistent with the claims of professors, leads us to interpret dissection exercises as the required setting of a specific experience, the place and time to acquire the knowledge that “builds the doctor.” Indeed, in the United States, anatomy professors insist that dissections are necessary for future doctors (3) and specifically introduce them as ”rights of passage” (4-5) following recommendations derived from early teachings about anatomy in the fourteenth century (6), with the same paradoxes and contradictions.
Beyond this necessity, the importance placed on practical anatomy varies across countries. In Italy, dissections have become optional, and sometimes students just see a film. In Lund, Sweden, dissections have been replaced by work at a computer with software that creates three-dimensional views of the body, simulating dissections.4 In Hannover, Germany, students work by anatomical zones studied from clinical examination, radiology, pathology … to dissections. In the US, medical students historically have had to perform dissections in small groups in their first year, often for a full semester (7-9). Nowadays, time spent in dissections seems to be shortening and even approaching disappearance globally (4), but the best students are encouraged to dissect outside of the regular curriculum (10). In Toulouse, France, dissections are still compulsory, graded and assessed by oral exams. However, each student does not have to dissect, as was the case until the 1970s.
From corpse to “anatomy”
During their first dissections, students go through an ordeal, physical and mental, which is intrinsic to their apprenticeship. Now as in the Middle Ages, one has to learn to overcome the offense made to their senses.
The first offended sense is smell. In Oman, over 90% of students reported being upset by the smells (11). Sight is the second tortured sense, because of the color and global aspect of the corpses. Not many students will actually touch them, those who dare will insist: the corpses have nothing in common with human bodies.
The confrontation of corpses leads students to manipulate them in ways consistent with the technical requirements of dissections, but that also changes these worrying bodies into “anatomies,” emblematic of the knowledge to be learned in lab work. A new code of perception and this new setting5 help students to distance themselves from their emotions. Meanwhile, using un-academic methods, they begin to professionalize their perceptions and ways of dealing with nakedness and death, also essential in becoming a doctor.
To protect themselves from the musty or decomposing smell of the corpses, they use many methods: perfumed handkerchiefs, scarves, turtle necks pulled over the nose, or, in England, Vicks VapoRub® (2). These have often now replaced tobacco smoking as a means of masking offensive smells. Thus, clouds of smoke or perfume allowed the students to submit corpses to a gradual metamorphosis: their repulsive materiality is replaced by waxwork dummies like those found in anatomical museums, meeting an image suggested by an English student in the 1940s about the anatomy lab : “A vast and sinister green-house growing waxen bodies in rows” (12).
A less common form of protection is fainting: “we were all obsessed by this idea: not to faint.” Sinclair, an American sociologist that studied medical apprenticeship in the late 80’s, notes that one of the first questions freshmen ask older medical students is, “Do people faint in the dissection room?" (13) . American students interviewed by Segal , an anthropologist that worked on medical students from the East coast in the 80’s, were more explicit: what they fear in fainting is that others might doubt their capacity to become doctors, showing how early the medical model is internalized (8). An interviewed Italian student said: “during dissections, the professor was judging their reactions in front of a cadaver and this was some kind of an ordeal.”
Other techniques are used to reify the corpses, such as dividing up of the body. This can be done virtually (to stand behind fellow students, to cover the rest of the corpse with cloth as during operations) (8); theoretically (to imagine sketches, to divide the body in regions, organs, systems…); or actually (to dissect a zone). Yet that process of reification meets resistance: some body parts are not easily “anatomizable”: faces and hands are usually hidden during dissections (3, 7, 11).
The manipulations of dead bodies to change them into “anatomies” serve the objectives of practical education. However, other images follow the breaking of the humanity of those beings and lead students into territory not directly related to the acquisition of medical competencies. The transformation of corpses into meat, shown through slang words meaning “meat” used to name them in France, allows students to reify them, to dehumanize them through an animalization that legitimates or at least excuses the violence done to them (14). References to a symbolic anthropophagy are not rare either, in gestures, comments, or practical jokes. For example, this scene, observed at the end of a dissection in Toulouse: Surrounded by other medical students, two students fought for the prerogative to hold the scalpel and cut the body. “Who wants some liver? Bon appétit. Come see the liver! It looks like foie gras (goose liver pâté)...” Suddenly, one of them, dissecting pliers in one hand, grabs the other’s surgical knife with his other hand, and handling his tools like macabre cutlery, leans towards the open thorax with a hungry look. It seems that breaking the taboo of opening the human body stimulates thoughts about violating the taboo of cannibalism, with one infamy bringing on the other.
Such assimilation can directly affect the students, especially in food revulsion: “The first time, I was not able to eat stew for a while for long!” A young English doctor confided that she had dreams where she was eating the flesh of the corpse she was currently dissecting (13). About five centuries earlier, after a week of dissection, Thomas Platter, a middle-age Dutch medical student who went around France and Europe with his brother during his medical studies, wrote in his diary that he had dreamt he had eaten human flesh and had woken up in the middle of the night to vomit. On both sides of the Atlantic, stories are told about lay people or students unwittingly eating pieces of corpses thrown in the soup by other students (15).
As a difficult victory over their disgust, the so called “meat fights” stories, circulated in France until the middle of the XXth century, in which students depict themselves or others “cutting the meat and throwing it at each other” during dissections, are the first spectacular evidence of the acquisition of manners that establish belonging to the medical profession, through a combination of disgust and liberating laugh.
Yet, vast differences are seen in how students engage in a similar experience. From the first dissections onward, around the table, a concentric organization is created, based on a hierarchy among actors, giving all the opportunity to participate in the collective ordeal. Those in the center who go too far and those in the rear who criticize others break implicit rules, yet participate in the experience. Female students have tended to be more passive and end up being the target of jokes--mostly obscene—made by their male counterparts, who view the dissections as a challenge and an opportunity to show-off. In a vast corpus of “cadaver stories” collected in the 80’s by an American anthropologist, Hafferty, some stories feature students cutting the penis of one cadaver to put it in another cadaver’s vagina, to shock female students, but in the more recent accounts, women play a more active role (15).
The anatomy lesson
This eruption and performance of violence, obscenity, and blasphemy do not capture all we observe during dissections. Opposed to such transgressions, paradoxically, other gestures and behaviors seem similarly necessary, echoing the paradox and ambivalence of those necessary as well as un-useful dissections.
In France, the first dissection is not preceded by official discourses on the respect of the sacred status of the dead, as in Italy or the US (3, 7). Students from Toulouse follow implicit rules that organize and limit even behaviors that seem uncontrolled. The first ones to criticize the violent behavior occasionally displayed by their classmates are those for whom dissections were hard to stand: “I am shocked because no respect is shown to Death.” Students perceive the need to limit what can from what cannot be done, the licit from the illicit.
Many behaviors may be observed during dissections that help define what students mean by respect. One turns around to sneeze, one says “sorry” when touching a corpse by chance, and one whispers next to corpses. Teachers and students use the word “patient” or “sick person” instead of corpse, and American students call themselves doctors and say “surgery” instead of “dissection” (8). The stillness of those lying bodies, tucked in their shrouds with eyes closed, turns those scary beings into quiet sleepers. Inviting a group of students to enter the lab, an assistant joked: “don’t worry, I’ve given them a sleeping pill!”
To respect corpses is first to admit their irreducible humanity. This is done throughout a series of queries that aim to give them a social identity. Students want to know age, medical history, causes of death, and life stories of their “patients.” Some American teachers recommend providing such information to (re)personalize the corpse and help students to remember that those people have lived before. To make “their” dead more familiar, some US students give the cadaver a name, or even carve them with their initials (8). In a medical school in Chicago, students have to write a biographic piece about the cadaver they are dissecting.
Identity can be given back more spontaneously yet more disturbingly through recognition. For example in Toulouse, two students said they believed they recognized their own grandparents. American students tell stories about removing the face cloth from a corpse and realizing with horror that it is someone from their immediate family9. This recovered humanity raises questions about the students’ own identity. If in corpses you see your own ancestors, does that not imply you belong to the same kind and same destiny? This helps to understand the uneasiness of students about dissecting bodies of young people. Though young corpses are more interesting to dissect, identification with them would be too close for comfort. This may also help explain the disinclination of medical students to donate their bodies to science (9, 13).
In the corridors of the lab, I saw a worried male student trying to make a female student smell his neck just after his first dissection. This smell is the first characteristic of the corpse. He or she who breathes it becomes impregnated with it: “I have a friend who, afterwards, always smelt his hands…” Smell is the first evidence of the transformation of the students. Medical books on occupational disease in the nineteenth century describe the sweat, urine and feces of anatomists as being impregnated with putrid miasmas that were seen as a main danger for doctors, together with poisonous infections that killed many of them.
The ordeal of intimacy with corpses forces students to see death, to overcome it more easily, but also to skim it, to face its danger. Today, when antiseptics and antibiotics help control the risks of septicaemia, teachers still give the same recommendations: “Be careful, don’t cut yourselves!” pompously changed by this impressed student: “With the slightest cut, you’re dead!”