Person or Specimen? Cadavers in the medical dissection lab

Christmas greeting card, school unknown, circa 1920.
Dittrick Medical History Center
from Dissection: Photographs of a Rite of Passage in American Medicine 1880-1930

Slate has an intriguing new review by Barron Lerner of a book called Dissection: Photographs of a Rite of Passage in American Medicine 1880-1930, by John Harley Warner and James M. Edmonson. The book delves into the turn-of-the-century practice of photographing medical students with cadavers - photos that today read as weird, grotesque, even offensive.

The photos unearthed by Warner and Edmonson depict an astonishing variety of attitudes toward cadavers. Some of the photos have the earnest, formal air of yearbooks (at least one is of a dissecting club, with the names of the members listed). In others, the cadaver seems to resemble a trophy: you can imagine a similar pose being struck by hunters or fishermen with their kill. Still others use the ancient conceit (which goes back to Vesalius) of depicting skeletons or muscle men as living, moving actors in dynamic poses: in one, the skeleton smokes a pipe with his dissector!

You can see a slideshow of the images here.

Looking at the photos, it's hard to know how one should react. On the one hand, one can dismiss these photos as youthful hijinks, or demonstrations of poor taste. My own experience with dissection students suggests they represent bravado in the face of death - gallows humor intended to mock, and thus defuse, our common mortality. Or perhaps it's the opposite: perhaps our attitudes toward death have changed since the turn of the century, and these medical students simply didn't find cadavers as disquieting as we do today. After all, in our world death typically occurs in a sterile hospital setting and loved ones may never see a lifeless body.

It's impossible to answer these questions without delving into the history of medicine and what exactly "death" means. The cadaver is a complex, socially constructed entity, laden with all kinds of meanings, from the frivolous to tragic to sinister to religious. But in the context of an anatomy lab, it's a specimen whose function is not to symbolize mortality, but to help us learn about the processes that supported life. In a teaching lab, we don't dissect the cadaver to know more about the unique person it used to house, but to understand universal, generic physiological processes. Balancing these different relationships with a cadaver is a challenge for any anatomy novice, and though these issues may have been differently weighted at the turn of the century, I imagine many of them were the same.

The authors of Dissection apparently have similar feelings. From Lerner's review:

Although the photographs may appear inappropriate to us, Warner argues, they commemorate a bonding experience between student and cadaver that was actually lost after 1930. After that point, he says, a new era of objectivity and detachment entered medical education, ending the earlier emotional attachment to the dissection process.(source)

But Lerner seems more concerned with a different issue: the fact that many of the cadavers are African-American, while their dissectors are white. Lerner suggests that might have been a reason why contemporaneous objections to the voyeuristic photos were few.

Warner rightly makes an analogy to the gruesome lynching photographs of the same era that were also distributed to genteel society through various souvenir cards. In a clever bit of historical detective work, Warner and Edmonson even discover that a particular photographer, G.H. Farnum of Oklahoma, actually took both types of photographs. Some of the dissection images contain racist inscriptions, such as "Sliced Nigger," from the Wake Forest School of Medicine and "All Coons Smell Alike to Us," from the College of Physicians and Surgeons of Baltimore. (source)

At this point, the modern reader is sure to recoil. Posing with a skeleton smoking a pipe is one thing, but racist slurs are another issue entirely in our culture, and rightly so.

The question I have, though, is whether African-American cadavers were generally treated much differently by medical students than white cadavers. According to the review, "students at African-American medical schools like Howard also dissected black cadavers and took photographs," so perhaps not. And if there is one thing I've learned about dissection, it's that as one continues, it becomes hard to distinguish gender, much less ethnicity. Dissection strips away the outward differences of age, skin color, socioeconomic class, and nationality, and gets down to the, well, bones of what it means to be human. And while that might just be my optimistic, modern interpretation, I find it hard to imagine that those turn-of-the-century doctors didn't come away from their dissection with an appreciation for how every human being is fundamentally similar. At least I hope so.

Lerner's account of Dissection reminded me of another book I blogged about a couple of years ago: medical resident Christine Montross' Body of Work. Since my post on that book post already expressed many of my feelings about how students relate to cadavers, I decided it might be useful to republish the original post here. So here is what I had to say about Body of Work in 2007. . .

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The LA Times recently reviewed Body of Work: Meditations on Mortality from the Human Anatomy Lab, a memoir by medical resident Christine Montross. I've been trying to decide if I want to read it, and I'm still uncertain. Although a relative novice when it comes to medicine (my degree is in molecular biology), I taught anatomy using human cadavers, and have dissected them. I never found cadavers the least bit disturbing. But I may be unusual in my detachment - my students reacted with disgust, distress, nervousness - and constant anxiety that their reactions weren't normal.

But what is normal? How should we relate to a donated cadaver in the anatomy lab - as a person, or a thing? Some reactions seem to be universal - gallows humor, for example. Humans have been laughing at death since long before Shakespeare. (What other weapon do we have? Death always wins, and the cadaver's the un-living proof of it.) We have some general rules of conduct - for example, treating the cadaver with respect, keeping the pieces of the various cadavers separate, covering face and genitals when they are not being examined. But such rules seem to be mostly for the students' comfort, since it's hard for a cadaver to retain modesty or dignity, at least in a traditional sense, when skin is missing and viscera are exposed.

Students respond to cadavers in personal ways, based on their own family histories, so one student's experience of dissection is unlike any other's. Everyone sees the cadaver differently: is this a person, or a patient, or a body, or a teaching specimen, or an illustration. . .? When students take limbs from a skeleton and hold them up to their own arms, turning them to determine the correct orientation, they enact a little unconscious ritual: memento mori. One student was fine with the cadavers until her grandmother passed away; after that, she found the cadaver so disturbing she couldn't be in the same room with it. The boundaries of life and death, previously comfortably clear, had blurred intolerably. Before class began, students came to me, concerned that they might find the body of a deceased relative in the lab: when and were and who, they wanted to know. (Why came much later.)

Montross' book takes on some of these issues. As reviewed by Harvard professor, poet and doctor Rafael Campo,

"Body of Work" is at its best when Montross, who is also a poet, allows us to observe the astonishing beauty her dissection reveals, and to relish the language she uses to describe it. "The language of these bones slides along their edges," she writes. "Os coxae, the hip bones. Their three parts, with names like flowers: ilium, ischium, pubis.... The pelvic brim, as if water spills over it.... Brim, arch, spine. The ligament names like a call to prayer: sacrospinous, sacrotuberous. Sacrosanct."

This wonder cabinet of anatomical language is familiar to any biologist. It is indeed beautiful. So is the body it describes. But Campo rebukes Montross for allowing such language to establish a clinical distance between herself and the life history of her assigned cadaver, "Eve:"

I believe it is the depersonalization first modeled for aspiring doctors in their encounters with cadavers that accounts for much of the lack of professionalism and career burnout in physicians, and the callous treatment patients too often receive nowadays.

Really: studying the body as beautiful, complex object is a precursor to treating living patients callously? I have never known anyone to leave an anatomy lab feeling less respect and wonder for human beings than before they began. Yet Campo wants the anatomical curriculum to explicitly address the spiritual, not just the physical:

In this age of frequently misapplied technology, here is a chance to make productive use of video cameras and monitors: Might not a video of Eve, telling of her life and created at the time she decided to donate her body, help mitigate some of the mistreatment Montross documents, as well as the subsequent distancing she (however uneasily) comes to approve?

A pleasant idea - and what I'd expect from the author of The Desire To Heal: A Doctor's Education in Empathy, Identity, and Poetry. Empathy should be part of the training of doctors and nurses alike. But is anatomy lab the right venue in which to share the life history of a cadaver? Personal details would increase the discomfort of beginners - in my experience, overly powerful empathy for the deceased disrupts their ability to cut and handle the body (a point Campo seems to dismiss). Would cadavers without life stories receive less respect or care than those who had documented their lives?

Isn't the point that regardless of our living identities, whether we are good or bad, our bodies are kin, after death and in life? When the cadaver was alive, it was home to a unique mind. Now that its cells are dead, is its role in the laboratory to elegize that mind - or to represent universal anatomical mechanisms? As a biologist, the answer seems fairly clear. Perhaps a doctor feels differently; I don't know. But I was disappointed as Montross appears to conclude her book by backtracking from scientific objectivity to elegaic ritual (with Campo's approval):

Great teacher," she intones, "I give you flowers. I carry your body to the funeral pyre. When you burn, may every space in you that I have named flare and burst into light." Thus she aligns herself with the humane tradition of honoring the dead, and the act of love inherent in tending to them. The detached concern she professes to want to emulate seems refreshingly absent here. Perhaps, in recognizing our universal and very human contradictions, there is hope for the beleaguered medical profession, after all.

Honestly, this leaves me cold. I can't speak for anyone else, but if my body ever ends up in a cadaver lab, I don't want people intoning poetry to it. I want them to dissect it. And yes, I said "it," not "me." I'll be dead. My body is a wonderful clockwork, but it ain't me.

The imagined ritual may be beautiful and humane, but it is a pleasant fiction, meant for the observer, not the observed. It has nothing to do with the cadaver's living identity - we have no idea who "Eve" was, nor if she even desired commemoration. Most importantly, the manifest beauty of the human body doesn't require validation by tradition or flowers (or words). We don't have to turn a cadaver into a spiritual symbol to make it a wonder: it already is wonderful, even in death. And if someone fails to understand that, I doubt they should be practicing medicine at all.

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Thanks to Mo of Neurophilosophy for the heads-up on the Slate review.