FOUR STUDENTS AND A CADAVER
By Anne Bennett Swingle | Photographs by Keith Weller
The thought of learning human anatomy by dissecting a corpse may unnerve new medical students, but mastering the experience can change them in ways they never expected.
t was an anxious group of medical students that hurried into the lab in the Preclinical Teaching Building last October 29. These were “first-years” about to get their cadavers, and many worried they’d feel nauseous at the sight of the dead body, perhaps faint. They seemed to grasp that the next seven and a half weeks of dissecting would test their technical skills, their ability to grasp tiny details about human anatomy and their very decision to become physicians.
Dressed in scrubs, gathering at lab tables in groups of four, the students eyed the 35 body bags on 35 tables arranged in three long rows stretching the full length of the 135-foot room. Here and there, skeletons hung from frames. Sinks and countertops were well stocked with boxes of vinyl gloves, white plastic aprons and bars of Lava. Wooden toolboxes fitted out with saws, chisels and mallets stood neatly near the tables. And the cloying scent of preservative fluid hung heavily in the air. One hundred forty-one students—120 first-years plus an assortment of Anatomy, Art As Applied to Medicine and Bioengineering graduate students–-awaited the word to begin.
At Table 15 three young men and one dark-haired woman examined the royal blue bag in front of them. Attached to the zipper with string was a small, white tag, much like those that mark objects at a yard sale, except that on this tag the letters W/M written in bold black ink stood for “white male.” Through the heavy vinyl, each student felt the shape of the form inside. It was rock solid, stiff. Not too thin, not fat. This would be their cadaver.
These four—Eric Weiss, Charlie Brown, Raquel Gomez and Josh Zeichner—had picked each other as lab partners because they had become good friends in the almost two months since medical school began. Two of them, Eric, a thoughtful Midwesterner, and Charlie, a confident Harvard grad, are roommates in Reed Hall. Raquel—amiable and engaging—lives opposite. And Josh, a gregarious New Yorker who knows how to make things happen, brought the lab group together.
In lectures they had listened to moving testimonials from second-years describing their relationships with their cadavers. They’d felt admiration for the men and women who had donated their bodies to science to help students like themselves learn. Now in the anatomy lab it’s all business. The time has come to remove their cadaver’s cover. Before they see him, they bow their heads, offering a moment of silence to what lies ahead. They stand two on each side of the table around him.
Then, Eric and Charlie rotate and lift the bag. “It’s pretty heavy,” Eric says nervously.
“How come it’s so big here?” asks Charlie, patting the area around the abdomen.
“The hands are crossed,” Eric explains.
“This is a body!” Josh exclaims
There’s Nothing Like the Human Body
Human Anatomy is divided almost equally between lecture and lab, with clinical correlations and discussion groups added to the mix. Computers play an integral role. Students take exams and fill out course evaluations on them. They also use software with high-quality images of cross-sectional anatomy and developmental embryology to supplement their lab work.
Computers, though, are not the centerpiece of the course. Dissection is. Enthusiasm on the part of the faculty for hands-on work in the lab is high, and indeed, current course director Mark Teaford might be a latter-day Franklin Mall, Hopkins’ revered first professor of anatomy (see box above). For just as Mall pressed for dissection as opposed to lecture, so Teaford favors dissection over current computer programs. “While some schools have gone almost totally to the computer, we feel that medical students shouldn’t learn solely in front of a terminal, or even just by the book, because nothing we have available right now is as detailed as the human body,” Teaford says. “Nothing gives us a better appreciation for three-dimensional relationships and for variation in each human body.”
Human Anatomy is hugely significant because it marks the moment when students start feeling a little less like bio majors and a little more like doctors. In the first two months of medical school they have eased slowly into the curriculum. They took Molecules and Cells, familiar territory since most had this kind of training as undergraduates. There was also time left over in those early weeks for activities like cooking suppers for one another in Reed Hall and just generally hanging out.
“This has been the best time of my life,” Raquel says. Being here among others who share her interests and goals has been intoxicating for her. She emigrated to the United States at age four from El Salvador during that country’s civil war and moved all around New York State with her family before settling in Poughkeepsie and winning a full scholarship to SUNY Binghamton. She wants to be a neurosurgeon, and Human Anatomy is a rite of passage, a milestone affirming her career beginnings. And yet for Raquel as for many, there is something about the centuries-old medical discipline that seems positively archaic in this era of the molecular revolution.
Indeed, people have been kicking Anatomy around for years, some even predicting that with advances in the computer, classes one day will be cadaverless. Lately though, there’s a feeling underfoot that the much-studied genotype can lend important, new perspectives to the organism as a whole and that good, old-fashioned, human gross anatomy—what physicians use every day to make a diagnosis, what surgeons probe in every procedure, radiologists in every scan—is alive, well and still very much the bedrock of medicine.
And yet few of the students have ever studied an organism in its entirety let alone dissected so much as a frog. For Josh, this seven-and-a-half week introduction to cutting might be the basis for his next 40 or so years. He says that right now he wants to be a surgeon. And because of his artistic sensibilities, he’s “thinking about plastics.” At the University of Pennsylvania he was editor of the yearbook and took most of the photos, did the layout and design. Plus, he once saw a breast reduction and admired the way surgeons put the whole thing back together again (“Boom, it’s a breast!”).
But now, here in the lab, at last face to face with dissection, he’s having second thoughts about a surgical future. “Once the original incisions are made, I know I’ll be fine,” he says. “This body is like a house that’s been lived in for a long time, and the person is letting us take a look inside. You want to respect that. And yet I know I’ll become desensitized,” he says, “I hope I don’t, because for as long as I can remember, I’ve wanted to go to medical school. Everyone correlates being a doctor with the study of anatomy. So this is what I’ve been waiting for, for 22 years, and now it’s finally happening.”
Just Like Grandpa
Then it’s Raquel, as the only woman in the group, who unzips the bag and exposes the body inside. There he is, their cadaver—a white male, about 75-years-old. They had thought the face would be covered, so the elderly, pleasant face and the sparse, grey hair catches them off guard. It is a paralyzing moment. He looks, they say, just like a grandpa.
Like new parents checking over their newborn baby, they examine him from head to toe.
Strange, dark spots on the chest—tracery of defibrillator paddles—suggest a fatal heart attack. A well-healed scar straight down the sternum, earlier bypass surgery.
And now Charlie prepares the cadaver for the first cut, running a red magic marker along the scar from the notch of the sternum to the last true rib. In lecture, the class had watched a 10-minute video depicting how to use the scalpel, the blunt probe, the scissors and forceps. So Raquel presses the point of the scalpel down into the leathery skin, slicing boldly and decisively. Then, as if embarrassed, they remember to cover the body, except for the area they’re working on (“like surgeons in the OR”). With scalpels in one hand, tweezers in the other, they set to work, pulling back the skin from either side of the chest.
Today their assignment is to find cutaneous nerves and vessels, and it’s hard going, searching amid the yellowish, fibrous tissue for that little speck of blue that indicates a vein, the elusive lumen of the sturdier arteries, the tough but tiny white cords that are the nerves. Everything seems impossibly small. Nothing is where it should be.
“I wish I were in lecture now,” Charlie says glumly, bent over the cadaver.
Josh, wearing a perpetual expression of disgust, does little dissection. The other groups, he notices, are way ahead. “Just think,” he says, glancing toward the windows, “people are walking outside in the sunshine, and they don’t know what’s going on in here.”
Anatomy Professor Ken Rose stops at Table 15. “The nerves shouldn’t break when pulled tight,” he says. “Unlike fiber, they don’t stretch.”
“You mean like a wire versus a rubber band?” asks Charlie.
“Sort of,” says Rose.
With his tweezers, Eric grasps what appears to be a tiny white thread amid a mass of lumpy fiber. “You think this is a nerve?”
A Couple of Long Balloons Equal a Heart
It’s Monday morning and in the first-year lecture hall on the ground floor of the Wood Basic Science Building, Professor Joan Richtsmeier is talking about how the heart develops in the embryo. She’s using her low-tech, tried-and-true props, a couple of long balloons, to show how the four-chambered heart develops from two cardiogenic cords. (Weeks from now she’ll deliver a knock-out, Web-based lecture on the pelvis and perineum with dozens of three-dimensional views.)
Developmental embryology was once an integral part of Human Anatomy, but when the curriculum was revised, it became a two-week course unto itself. But because the new course focused principally on cellular and molecular changes and not on the organism as a whole, students weren’t learning about the development of the fetal heart, for instance. So classical organ-level embryology recently was reintroduced to the anatomy course.
Like Teaford, who works in Costa Rica and Africa studying modern and fossil teeth, chewing and the diet of primates, Richtsmeier is a biological anthropologist. Her research interests lie in the growth and development of the skull. Along with four other senior anatomy faculty, they are part of the department’s long tradition—its strength and staple—in anthropology, comparative anatomy and paleontology. Each has worked in a different part of the world studying primates, dinosaurs, modern humans and their ancestors. “But the glue that binds us together,” Rose says, is a common interest in functional anatomy and evolution. Today it’s hard to find faculty who are using human anatomy in their daily research to help interpret fossils, but it seems that every day, I’m picking up a bone.”
Along with two post-docs and two graduate students, the six faculty members are the lab instructors for first-year anatomy students. Some two dozen others, including luminaries like University President William Brody speaking on medical imaging and pediatric neurosurgeon Ben Carson on the brain, guest lecture and present clinical correlations. They are, says Teaford, “an incredible tool to have at our fingertips, and it shows a real commitment to treat the course as more than just an isolated basic science.”
That trickle-down sound is preservative fluid hitting the bucket under Table 15, as the students prepare their cadaver for day two of dissection. The major muscles covering the chest wall have been identified, the entire surface of the pectoralis major cleaned.
“I’m cutting today, I’m ready to cut,” Josh says to no one in particular. “Okay, this is what I’m thinking. This area here,” he says, pointing to the pectoralis major, “just dive in.” Gently, and with his gloved fingers, Josh separates the large upper muscle from the thinner pectoralis minor underneath, and voila: a well-defined group of pectoral nerves and arteries. Raquel uncovers the medial pectoral nerve (“a lovely medial,” says Rose); Charlie, the thoracoacromial artery and lateral pectoral nerve. At Table 15, things are looking up at last.
Now, though, there is the matter of the chest wall. It has to be sawed off. Gradually, throughout the lab, saws begin to whir—low and steady, then high-pitched and whining. It’s way past one, but the students are totally engaged, oblivious even to the terrible burning smell. “This,” Josh exclaims, “is orthopedics!”
Later, over lunch in the Outpatient Center cafeteria, the four partners take stock of their first two days in the lab. “Today, I was more confident,” Eric is saying. “We knew what we were going to do, we worked at a good pace, and we found the things we needed to find quicker.”
“My parents asked about seeing the body for the first time, but that’s all,” says Charlie. “They really don’t want any more details and neither do most of my friends.”
“In a way,” says Raquel, “this is like a college fraternity or sorority. You do things you don’t talk about. This is more special, more intimate, and it binds us together.”
Too Much, Too Hard
It’s November 22, a crisp Monday morning, but the spark is gone from the group as they trudge up Monument Street on the way to anatomy lab. Charlie spent the weekend in New York and then New Haven for the Harvard-Yale game, but other than that it’s been pretty much a period of dissection, day in and day out. No more home-cooked suppers in the dorm, no more hanging out having fun.
Most days, lab starts at eight and goes straight through until one. The course has never been this short before, and the schedule is grueling. The class is reading some 60 pages of dense, new material each night, and with more clinical correlations, lab presentations, discussion groups and developmental embryology, the course is meeting for more hours at a time.
It’s not easy to dissect the entire human body in seven and a half weeks. Teaford says his colleagues overseas simply don’t understand how it can be done, but the caliber of the students is what makes the difference. “If they weren’t this good, it wouldn’t work.”
In the past weeks, the four partners at Table 15 have moved from the thorax to the abdomen and then to the dreaded pelvis and perineum. “I absolutely hated it,” Josh exclaims. “It was too much, too hard to see.”
Charlie, on the other hand, sailed right through. He’s almost certain he wants to be a urologist. Starting as a high school student growing up in Baltimore, he spent five summers working in a Hopkins urology lab. At Harvard he’d played lacrosse and after graduating took a year off to live in Spain and teach eighth grade chemistry and physics. He’d learned to paint with watercolors and cook Basque food.
A meticulous dissector, Charlie can work without stopping for hours on end. Eric and Raquel are efficient. They do what’s necessary. Josh is the fastest—sometimes too fast, the others say—a point of contention. “Look,” Josh says, “you can’t be in medical school for 10 years. It can take your life to learn this.”
Today in the lab, the floors are slippery with liquified fat, the air thick with the nauseating, insidious stench. The cadavers—table after table, row upon row of them—are ghoulishly illuminated by a harsh, overhead fluorescence, and the room seems enveloped by an eerie chill.
The students wear double sets of gloves and dab Vicks Vapo-Rub under their noses. Charlie and Raquel are dissecting the arm. As a collection principally of muscles, it is at first disappointing. But they are making quick work of it, revealing the biceps, the triceps, the brachials, and proceeding to the more interesting flexors and extensors of the forearm. Meanwhile, Eric and Josh, on the other side of the table, are into nerves and vessels, dissecting the axilla. Eric is paying close attention, because on the Monday after Thanksgiving, he’ll be presenting to his lab group on the limbs. Using his cadaver, responding to a professor’s questions, each student goes through two of these performances, and preparation is intense.
Experts at Cutting
Thanksgiving vacation has come and gone, and for Eric Weiss it had not gone well. He’d traveled to Puerto Rico, caught the flu, and was so sick on returning to school he couldn’t make his limb presentation. That meant he was left with the course’s last two presentations. Both would be on the head and neck, arguably the most challenging of all parts of the human body to master. His first presentation is a success, though, and now as he faces tomorrow’s on the pharynx, larynx, nose, tongue and mouth, his confidence is high.
Eric studied marine biology and ecology as an undergraduate at Vanderbilt and made five separate trips to the Baja Peninsula, researching plant-eating insects. He loves the desert, the ocean, yet chose medical school because he wanted a career in genetic medicine. Lately, thanks in part to the influence of his surgeon preceptor, not to mention seven weeks of dissection, he’s been thinking about surgery.
Recently, things have been easing up for the group. They’ve been playing volleyball, they went to the theater to see Chicago. (Says Josh: “It felt like real life again.”) And now, on December 20, the final day of dissection, the lab is suffused with a celebratory spirit. Just one more presentation, one last test and it’s home for the winter break. As the cadavers have slowly come apart, their organs and tissues disposed of, the odor has abated, a tremendous weight lifted.
At Table 15 what remains of this old man whom the four students came to regard almost as a friend is a skeletal frame covered by a grimy, white blanket. To one side is the skull cap, and in that, the brain, split into two parts. Charlie is dissecting the mouth and larynx, and the others are quizzing one another on the upcoming final exam, their steel trap minds spewing out endless anatomical minutiae. Among the professors they are known as “a very sharp group.” All are ace dissectors, and recently in fact an instructor dubbed them “experts at cutting,” a remark that escaped no one’s notice.
Now Charlie is performing a complicated, challenging dissection of the middle ear, revealing the auditory ossicles, the tiny bones that carry vibrations from ear drum to inner ear. It somehow seems appropriate, Josh remarks, to conclude the course with the elusive stapes—at 5 mm the smallest bone in the body.
It’s all over now, this journey of discipline and discovery. These four have touched and tugged, cut open and taken out together. They’ve stood for hours, bent over the table (always bent), worked head to head, shoulder to shoulder. Their old man has provided them with a text that no computer program could duplicate, no series of lectures could match. And though he now has been cut and torn asunder, in the minds of these four future doctors, he will live on and on.