Dissecting Gross Anatomy

1 EDITOR S NOTED issecting Gross AnatomyTeri A. Reynolds, PhDIN THE1951 FILMPEOPLEWILLTALK,DRNOAHPRAETORIUS,A PHYSI-cian played by Cary Grant, is followed everywhere by a large, silentman. The man is with him as he addresses an Anatomy class, as heconducts the student orchestra, as he stands over a patient in the op-erating room. The man speaks only at rare moments, each crucial, com-ing to Noah s aid as the voice of wisdom, of conscience, or of the Noah is finally challenged by a university tribunal to defendhis relationship with the odd man he calls my friend, the story comesout: the man is a convicted murderer, executed by hanging and sent20 years earlier to Noah, a medical student who needed a cadaver ofmy own. The cadaver awakened as soon as Noah stuck a glovedfinger in his mouth, and has never since left his experiences in the Anatomy laboratory underpin later prac-tice in ways that are not easy to articulate.

2 The knowledge gained thereguides diagnosis, allows us to link phenomena that seem on the body ssurface to be unrelated, and gives us fluency in a discourse that letsus to describe what is happening to our patients. Visualizing the struc-tures hidden beneath the skin allows us to identify conditions other-wise beyond our grasp. Although the overwhelming bulk of the knowl-edge we use to care for patients is learned outside the lab, and thecentrality of the experience wanes even by the end of first year, whatwe learn in Anatomy lab is somehow, quietly, always this issue ofMSJAMA,literature professor John Bender recountshis season as an outsider in the lab and describes how the process servesas a ritual entry into the medical profession.

3 Beyond the technical knowl-edge it affords, Anatomy lab links us to the past and begins our so-cialization to future practice. We dissect knowing that we are makingthe same cuts and seeking the same structures as physicians centu-ries earlier. But today, we pride ourselves on taking more from theexperience, on engaging with the gift that is the donation. SamanthaStewart and Rita Charon describe Anatomy study as an initial con-frontation with life and death that will follow us throughout our ca-reers, and discuss a way these early lessons might be retrieved. S. RyanGregory and Thomas Cole describe the history of dissection acrosscenturies, while Aaron Tward and Hugh Patterson account for the shiftfrom grave robbing to cadaver donation in the United States.

4 Finally,to launch our new creative writing sectionmurmur, Matthew Ehrlichevaluates his cadaver s chief first body in our care has neither the needs nor the agency of apatient, and yet for many of us, it is the body we will envision as weexamine the intact surface of each patient who comes to us. Whetherit is our initiation into the professional tribe of physicians (Bender), the scientific method (Gregory and Cole), or the use of affectiveresponses (Stewart and Charon), Anatomy lab is as much a part ofhow we see as what we know. The trouble with you, Elwell, Noah s ally says to his accuser atthe end, is you ve never had a cadaver of your own. ON THE COVERMike Javernick,GeorgetownUniversity Schoolof Medicine,Amnion, pastels andcharcoal on paper, P.

5 WeisbergColumbia UniversityCollege of Physiciansand SurgeonsDeputy EditorsAlison J. Huang, MPhilUniversity of CaliforniaSan FranciscoSchool of MedicinePam RajendranBoston UniversitySchool of MedicineAssociate EditorsRahul RajkumarYale UniversitySchool of MedicineTeri A. Reynolds, PhDUniversity of CaliforniaSan FranciscoSchool of MedicineJohn F. StaropoliColumbia UniversityCollege of Physiciansand SurgeonsJane van DisUniversity of South DakotaSchool of MedicineJulie Suzumi YoungDartmouthMedical SchoolAmir ZarrinparUniversity of CaliforniaSan DiegoSchool of MedicineJAMA StaffStephen J. Lurie, MD, PhDManaging EditorJuliana M. WalkerAssistant EditorMSJAMA provides a forum for criticalexchange on current issues in medicaleducation, research, and practice.

6 It isproduced by a group of medical studenteditors in collaboration with the JAMA editorial staff and is published monthlyfrom September through May. Thecontent ofMSJAMA includes writing bymedical students, physicians, and otherresearchers, as well as original medicalstudent artwork and creative articles and viewpoints inMSJAMAdo not necessarily reflect the opinionsof the American Medical Associationor of JAMA. All submissions must bethe original unpublished work ofthe author(s). All submitted workis subject to review and submissions and inquiries to:MSJAMA, Stuart P. Weisberg, Editor,100 Haven Ave, Apt 19B,New York, NY 10032;e-mail: 6, 2002 Vol 287, No. 9(Reprinted) 2002 American Medical Association. All rights reserved. at Columbia University, on February 1, 2007 from ARTICLEFrom Theater to LaboratoryJohn Bender, PhD, Stanford University, Stanford, CalifAS A PROFESSOR OF COMPARATIVE LITERATURE AND A SPECIAL-ist in 18th-century literature and art, I was a freak when inthe fall of 1995 I joined 3 first-year medical students anda 50-year-old woman dead of heart disease on a team inthe Stanford Medical School s introductory Anatomy purpose was not to lay the foundation for a career inmedicine but to gain a richer understanding of early ana-tomical works and the old culture of dissection that I hadbeen studying as part of a project on science, the novel.

7 Andthe visual research has explored the crossover between ways ofvisualizing the body in anatomical atlases and in pornog-raphy. Expensive books of both kinds were often shelvedtogether in private libraries in the 18th century, the periodwhen, according to today s experts, modern pornographywas kind of strict, linear perspective associ-ated with painting from the Renaissance onward fused inthis period with new analytic ways of making mechanicaland scientific diagrams. This fusion produced both a mod-ern level of precision in works of Anatomy and new eroticeffects arising from close-up looks at the body that seem tocome from secret, hidden vantage points. In fact, for me,the most chilling experience in the dissection room was notcutting open the penis and testicles of the male cadaver atthe next table, although friends asked about this and fel-low males in the class worried about it.

8 Rather and per-haps not surprisingly for a historian of art and vision mycrisis came when one of my partners dove into the globe ofan eye, extracting the iris, lens, and the rise of modern anatomical studies in universi-ties and academies in Italy of the 16th century to the era ofincreasingly rigorous professional education and certifica-tion during the 19th century, the spectacle of dissection wasquite available to members of the public. They might be pa-trons, artists, or even ticket-buying curiosity seekers whohad paid a high price, but they certainly were not ,3 The title page of Andreas Vesalius 1543 DeHumani Corporis Fabricashows a veritable mob strainingto see the open female corpse in the foreground. Apart fromits formal architecture, the scene is more like a booth at afair than a contemporary laboratory where medical stu-dents learn Anatomy .

9 Much later, William Hunter, who pub-lished the first complete atlas of the pregnant uterus in 1774,gave demonstrations at the Royal Academy in London forpainters, sculptors, and paying members of the public. Thiscontrasts with today s experience, in which physicians walkthrough society with the aura of privileged initiates to a mys-terious and frightening study in Gross Anatomy works to initiate thenewly arrived into the professional tribe of physicians. Medi-cal students experience this aura in part through the place-ment of the Gross Anatomy course as a threshold experi-ence at the beginning of their curriculum. The dailyencounter with the cadaver throws a veil of mystery aroundthem for family members and friends. Like them, I quicklynoticed that it only took a few minutes before friends askedwhether we were cutting up Anatomy theater lies at the mysterious heart of medi-cine in the public fantasy and the professional imagina-tion.

10 To open a human body is to enter the realm where lifeand death cohabit, and the didactic dissection of corpses traf-fics in death and disrepute. (The corpses for anatomical dem-onstrations used to be stolen from graveyards or cut downfrom gallows.) In the past, however, transgression of the ta-boo did not coincide with professional initiation as it doesnow. In contemporary medicine, Anatomy works as a thresh-old experience for medical professionals because they aloneviolate the taboo as part of their training. The content ofthe knowledge depends on the violation of the taboo (ac-cess to the interior of the body and to death); its profes-sional efficacy, on the transformation of the Anatomy the-atre into a delimited professional did I learn in my Anatomy course?