MBBS MMedH FRACS FRCSC FACS
Emeritus Consultant Neurosurgeon, Royal Prince Alfred Hospital & The Children’s Hospital, Sydney; Lecturer in Surgical Anatomy & Clinical Associate Professor, University of Sydney
Saturday, April 14th, 2018
Rembrandt’s painting “The Anatomy Lesson of Doctor Nicolaes Tulp” in 1632 makes it clear that human anatomical dissection had become one of the spectacles and symbols of the age. Anatomy had become accepted as a portal into the human condition . In many ways, it can be viewed as part of the cultural movement of the Renaissance, despite human dissection existing primarily as a procedure of medicine .
Wide-ranging circumstances influenced the revival and unfolding of human anatomy. Anatomical dissection became the cutting edge of medical investigation and the essence of a doctor’s training. This anatomical revolution brought about a paradigm shift away from the traditional thinking of the body and its relationship with the mind and soul, which had so dominated medieval thinking .
Human cadaveric dissection was first introduced during the third century BC at the School of Greek Medicine in Alexandria, championed by Herophilus, but this was subsequently not allowed under Roman rule . Galen, in the second century AD, became the anatomical authority; however, all his dissections were on animals, and the extrapolation of his findings to humans resulted in inaccuracies not corrected until the time of Vesalius . His huge collection of work was written in Attic Greek, the contemporaneous language of science, and was largely lost with the fall of Rome .
Medieval medical practice , carried out mainly in monasteries with small charity hospitals, was dominated by religious values to an extraordinary degree. The declaration of Pope Innocence the Third in 1215 forbade clergy from engaging in any activities likely to cause bloodshed . This prevented clerics from practicing surgery or studying anatomy. Surgery was left to layman practitioners, who were mostly uneducated manual workers, degraded by their contact with blood .
With the beginnings of vernacular literature and the founding of the first universities, a more humanistic approach to medicine developed . This coincided with a revival of Greek culture, science, and mathematics, together with advances in industrialisation. The city of Salerno was famous as a health centre since Roman times, and it developed an orientation around Greek medicine when its archbishop, Alphanus, travelled to Constantinople in 1063 . As well as introducing Byzantine and Islamic medicine, a crucial advance came with the re-discovery and translation of Galen’s anatomical texts from Arabic into Latin . This allowed the sharing of medical thinking, and a specialised vocabulary was generated, which provided a framework for medical teaching . A foundation medical text called The Articella was created, and this was used throughout the newly-established medical schools of Europe by the mid-12th century .
Anatomical knowledge was boosted by the discovery of Galen’s text On Anatomical Procedures, which was a treatise on how to carry out a dissection . The first public record of a systematic anatomical dissection was in 1315 on a condemned criminal at the Bologna medical school by Mondino de Luzzi . De Luzzi subsequently wrote the standard anatomical text for the time based on the Galenic model . Dissection based on this model soon became part of medical education in universities across Europe, and authorities began supplying condemned criminals to medical faculties for human anatomical dissection .
The anatomical basis of medicine paved the way for its foundation as a rational science . However, the idea that dissection might be used to verify, or even correct, established medical thought was still quite alien . A typical dissection scene consisted of the physician, in his academic robes, sitting high on a throne reading from a Galenic text, whilst a surgeon dissected, aided by a teaching assistant pointing out anatomical details . The goal was not to add to knowledge, but to verify the text in which the knowledge was enclosed . Surgical benefits were rarely mentioned, and surgeons still learned their anatomy by practical apprenticeship .
By the 16th century, permanent anatomy theatres were built to accommodate a growing audience, including laymen and artists . University anatomy dissections became somewhat theatrical events lasting many days, followed by banquets in an almost carnival-like atmosphere . Enthusiasts of anatomy included Renaissance artists, such as Leonardo da Vinci , and a revival of naturalistic art involved them in not only attending dissections, but in performing their own . The new involvement of artists with anatomy resulted in more realistic medical illustrations, which became increasingly available .
Andreus Vesalius, at the University of Padua, not only transformed research in human anatomy, but also, equally profoundly, the teaching of anatomy. Vesalius based his research and teaching on the dissections of cadavers he carried out himself, in contrast to his contemporaries . He rapidly exposed Galen’s anatomical errors, and published his beautifully illustrated seven-volume book De Humani Corporis Fabrica in 1543. This marked a turning point in the understanding of the human body, and Vesalius’ core ideas became the essence of the new anatomy .
Over time, cadavers became increasingly difficult to obtain. Clandestine acquisition of bodies, including grave-robbing, together with fear of vivisection in the community, caused increasing public disquiet regarding anatomical practice . A gradual decline in public dissection developed, despite the practice being considered a linchpin of surgical training and an important component of medical education. The dubious morality surrounding the procurement of cadavers was mitigated with the British Anatomy Act of 1832 which allowed for body donations, and excluded the use of executed criminals . This was a paradigm shift in the procurement of human cadavers for anatomical dissection.
The teaching of anatomy by dissection has gradually declined in the modern era, often replaced by virtual and digital imagery to save time and money . Many have reasoned, however, that clarity of understanding regional relational anatomy and construction of a mental three-dimensional representation of the human body, cannot occur without anatomical dissection . Some research has shown that decreased use of dissection as a teaching tool is one of the factors that can have a negative influence on the anatomical skills of medical students and, somewhat paradoxically, leads to a decline in anatomical knowledge .
The lack of anatomical knowledge in students reaching their clinical years, and by extension surgical trainees, led to a review of the University of Sydney Medical School program and re-introduction of a whole-body dissection course in 2009 . Subsequently, the pass rate in anatomy for the Generic Surgical Sciences Examination (GSSE) went from 57% in 2007 to 92% in 2015 for graduates of the university.
There are also other considerations. The handling of a human cadaver encourages humanistic qualities in medical students, and provides some insight into the meaning of human embodiment and mortality . Indeed, some would argue that human cadaveric dissection represents a profound rite of passage into the medical profession .
Vesalius was a pioneer of medical illustration in medical teaching, but he saw this only as an aid to learning . He insisted that anatomy could only be studied and understood by inspection of the human body through dissection . Despite the passage of 500 years since his birth, this principle still remains of enduring relevance today.
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