nhsmanagers.net Briefing 8 July 2017 Medicine for Managers Dr Paul Lambden BSc MB BS BDS FDSRCSEng MRCS LRCP DRCOG MHSM FRSM Dissection The fundamental understanding of the human body was mapped out by practitioners of medicine over many centuries to understand both normal structure and function and the changes associated with disease. The word dissection comes from the latin verb dessicare. Until recently, things had changed little for over two centuries. Dissection has been a tool of medicine since about the end of the fourth century BC. Before that time there were constraints on the mutilation of human corpses because the body itself was treated as sacred, which resulted in relatively little knowledge of the inner body and some very fanciful concepts of what might be within. In this respect Hippocrates, the father of medicine, was denied a key component of medical knowledge. As in so many aspects of medicine, the Greeks led the way. Aristotle and his followers embarked on a programme of dissection of both human and animal corpses and at about that time Diocles published the first book on dissection, although it was confined to animals. In 280 BC Herophilus investigated the human body and gave names to some of the structures that he found within. He dissected the eye and recognised the significance of the pulse as a guide to illness. At the same time Erasistratus dissected the brain to try to understand the association between structure and movement. He did not agree with the teachings of Hippocrates, saying that he did not accept the concept of humours. He thought that arteries were full of air (pneuma) and that the blood he found was seapage from organs. For the period of the rule of the Roman empire dissection was banned. The thirst for knowledge drove physicians to use other
Restrictions continued to be relaxed and in 1537 Pope Clement VII accepted the teaching of anatomy by dissection. The Church was content to allow dissections to occur provided that the bodies were given an apppropriate Christian burial afterwards. cadavers and Galen used macaque monkeys as a proxy for human anatomy to improve his understanding. The power of the Roman Catholic church, driven by the belief of the sanctity of the body and that it belonged to God, not man, resulted in the church s opposition to dissection. Ecclesiastical opposition to dissection faded away during medieval times. The first formal dissection of a human corpse was credited to Mondino Liuzzi in Bologna around 1315. During the Black Death, which occurred between 1346 and 1353, the Papacy sanctioned postmortems to search for the cause of the disease. However, dissections continued to be a rarity. Since the middle of the thirteenth century there had been post-mortems carried out by surgeons to discover causes of death. The corpses selected for university and medical school dissections were generally those of criminals and witches. Italy became to centre of medical knowledge through dissection. Dissections became ever more public occasions and spectacles where the anatomist, a professor, would sit in a high chair, dressed in ceremonial robes reading from the works of Galen whilst pointing to structures in the body (which was very rarely that of a woman). Leonardo da Vinci drew over seven hundred and fifty anatomical drawings during this period. Anatomy took a step forward with the work of Andreas Vesalius, born in 1545, he rose to become court physician to Emperor Charles V of Rome and Philip II of Spain. He published De Humani Corporis Fabrica (On the Structure of the Human Body) in 1543. This was a beautifully illustrated and
published his groundbreaking work on the heart and the circulation of the blood in 1628. detailed book and challenged the work of Galen who had used animal dissections. Vesalius work produced sound anatomical data based on firsthand observations. Developments occurred quickly in Italy. Ambroise Parė developed his surgical techniques using the anatomy of Vesalius and other notable physicians of the time and later added quickly to the data with Falloppio at Padua identifying the Fallopian tubes. Towards the end of the century, Eustachio recognised the Eustachian tube and the Eustachian valve of the heart as well as many other structures. Eustachio s pupil, Fabrizio, undertook detailed work on veins which provided the inspiration for the English physician William Harvey who Of course, during this period anatomical knowledge expanded rapidly but it is clear that, at that time, knowledge of structure far outweighed knowledge of function. The development of surgery brought with it an increasing thirst for knowledge of the body. Centres developed in England and in Scotland, most notably in Edinburgh. The progress of training, the expansion of the Royal College of Surgeons, the development of the hospitals and the management in those hospitals of the more severely ill and those suffering accidents and emergencies proved very valuable for the surgeons. Many bodies were unclaimed after death because they had been poor and surgeons and their students were able to dissect post-mortem without restraint. Alongside hospitals, schools of anatomy developed boosting the prestige of surgery. Surgeons attached to the army also obtained a rich source of bodies in times of war (which was frequent).
Operations to treat wounds often subsequently became dissections to establish the extent of the fatal injuries. Anatomy and dissection developed further and by the 18 th Century, it had been recognised as key to the understanding of the body and anatomical structure. John Hunter was a pre-eminent anatomist of his day. Born in 1728, in Scotland, he initially the mechanism of evolution (Darwin published the Origin of Species nearly a century later in 1859). Hunter is said to have had 14,000 specimens which were later housed in the Royal College of Surgeons (many destroyed by a World War II German bomb). He established a dissection school in Leicester Square and, following his death in 1793, students found that the body on the dissecting table the following morning was his own. Hospitals developed museums for collection of specimens and training purposes. worked with his brother who developed an anatomy school in Covent Garden in London. He reputedly did over 2,000 dissections in the twelve years that he worked in his brother s school. After a period in the army he returned to London and developed his anatomy interest. He became surgeon at St George s Hospital and pioneered obtaining consent to do post-mortem dissections, including of the rich and famous. He also used grave robbers and purchased a large sum of money for the skeleton of Charles Byrne, the Irish Giant. He also did a huge amount of work on animals and recognised that humans and animals came from common ancestors, though he did not work out Perhaps one of the best-known is the Gordon Museum at Guy s Hospital in London. A collection of specimens had been started at the hospital in 1802 but the museum was established in 1826 with donations, notably from Robert Gordon. Not only does it have thousands of specimens illustrating all pathology but it also houses an amazing collection of over 200 wax models of dissections produced by Joseph Towne. They are anatomically accurate and have been an extremely
Many students, when questioned about dissection, felt it aided learning and made anatomy more interesting. Others did not like the smell, found it timeconsuming or just boring. Those views may, of course, be influenced by the aspirations of students and whether their interests were more with a medical or a surgical career. valuable educational resource for over 150 years. Dissection became a central part nof medical training at the medical schools in the nineteenth century and so it continued until the latter part of the twentieth century. Shortage of specimens and questions about the value of systematic teaching of anatomy by carrying out the dissections has resulted in the omission of, or a significant reduction in the use of cadavers. It would be a considerable loss if dissection did not continue as part of the undergraduate curriculum and it is to be hoped that, amongst all the other learning techniques available, it retains a place, echoing the learning of generations of physicians and surgeons for two-and-a-half thousand years. paullambden@compuserve.com In parallel, the earlier involvement of patients in education, the development of problem-based learning and of course the explosion in models and computerised three-dimensional training aids had dramatically changed the facilities available for learning the relationship of bodily structures. As someone who did eighteen months of dissection as a pre-clinical student, for me it was a positive experience and was the first interaction between medical study and the human body.