Let the dead teach the living: the rise of body bequeathal in 20th-century America.

America's medical schools have long used human cadavers to teach anatomy, but acquiring adequate numbers of bodies for dissection has always been a challenge. Physicians and medical students of the 18th and 19th centuries often resorted to robbing graves, and this history has been extensively examined. Less studied, however, is the history of body acquisition in the 20th century, and this article evaluates the factors that coalesced to transition American society from body theft to body donation. First, it describes the legislation that released the unclaimed bodies of those dying in public institutions to medical schools for dissection, thereby effectively ending grave robbery. Then it discusses midcentury journalistic exposés of excesses in the funeral industry-works that were instrumental in bringing alternatives, including the previously unpopular option of body donation, to public consciousness. Finally, it examines the rise of body transplantation, the Uniform Anatomical Gifts Act of 1968, and the subsequent state of willed-body programs at the turn of the 21st century. Body-donation programs have gradually stabilized since and currently provide most of the bodies used for dissection in American medical schools. Relying as they do on public trust, however, these programs remain potentially precarious and threatened by public scandals. Whether American medical schools will receive enough bodies to properly educate students in the future remains to be seen.     

From cradle to grave via the dissection room: the role of foetal and infant bodies in anatomical education from the late 1700s to early 1900s

The preponderance of men in the narrative of anatomical education during the 1800s has skewed the historical perception of medical cadavers in favour of adult men, and stifled the conversation about the less portrayed individuals, especially children. Although underrepresented in both the historical literature and skeletal remains from archaeological contexts dated to the 1800s, these sources nevertheless illustrate that foetal and infant cadavers were a prized source of knowledge. In the late 1700s and 1800s foetal and infant cadavers were acquired by anatomists following body snatching from graveyards, from the child's death in a charitable hospital, death from infectious disease in large poor families, or following infanticide by desperate unwed mothers. Study of foetal and infant remains from the 1800s in the anatomical collection at the University of Cambridge shows that their bodies were treated differently to adults by anatomists. In contrast to adults it was extremely rare for foetal and infant cadavers to undergo craniotomy, and thoracotomy seems to have been performed through costal cartilages of the chest rather than the ribs themselves. However, many infants and foetuses do show evidence for knife marks on the cranium indicating surgical removal of the scalp by anatomists. These bodies were much more likely to be curated long term in anatomical collections and museums than were adult males who had undergone dissection. They were prized both for demonstrating normal anatomical development, but also congenital abnormalities that led to an early death. The current findings show that the dissection of foetal and infant cadavers was more widespread than previous research on anatomical education suggests. This research details the important role of the youngest members of society in anatomical education during the long 19th century, and how the social identity of individuals in this subgroup affected their acquisition, treatment and disposal by elite medical men of the time.     

Anatomists’ views on human body dissection and donation: An international survey

A survey was conducted to test three hypotheses: anatomists believe that dissection by students conveys not just anatomical knowledge but also essential skills and attitudes, including professionalism; anatomists approve of the donation of their own bodies or body parts/organs for medical/health-care training and research; attitudes towards body dissection and donation are not dependent upon gender or upon the extent of teaching experience, but are related to transcendental convictions relating to beliefs in the afterlife. Eighty-one anatomists, from 29 countries responded to the survey; 80% indicated that they required medical/health-care students to dissect human cadavers (60% females–86% males, p = 0.02). Most teachers recorded that dissection was an instrument for training undergraduate students, an instrument for the development of professional skills, and an instrument to help to control emotions in the future doctor rather than being only a means of teaching/learning anatomy facts. Males were more receptive to the concept that dissection helps to control emotions in the future doctor (p = 0.02). Most teachers (75%) said they were willing to donate their bodies, 41% saying they would donate body organs only, 9% would donate their entire bodies only, 25% would separately donate organs and also the entire body. The willingness to donate increased significantly with the years of teaching experience (p = 0.04). Teachers who were not believers in the afterlife were more likely to donate their organs/bodies than were believers (p = 0.03). Our findings showed that anatomists’ attitudes towards body dissection and donation are dependent upon gender, upon the extent of teaching experience, and upon transcendental convictions.     

The evolving ethics of anatomy: Dissecting an unethical past in order to prepare for a future of ethical anatomical practice

Anatomical practice has arguably one of the most ethically challenging histories in the medical sciences. Among the oldest scientific disciplines in medicine, dissection of the human body for scientific purposes occurred as early as the third century Before the Common Era. Throughout the history of anatomical practice, human dissection has occurred in ways that cross the line from progressing medical science to violating the sanctity of the human body. The dissection of the human body creates ethical dilemmas which stem from the need for anatomical science to gain medical knowledge in juxtaposition with prevailing religious and moral views surrounding anatomy as a threat to the sanctity of the human body. This article examines the unethical history of human dissection throughout the ages and explores the rationale behind the unethical practices. In addition, this article explores imperative modern day ethical standards in anatomy including, the ethical handling of human bodies, respecting human life, and ensuring informed consent for dissection of bodies that are donated. Finally, this article explores the question of which ethical prism we should use when dealing with anatomy collections or works of the past. Learning both the history of unethical practices in anatomy and the rationale behind them is imperative so that the discipline can prepare for an ethical, diverse, and inclusive future. This article provides a foundation for understanding the evolution of ethics in anatomical practice and is a valuable resource for students and anatomists alike.     

Dark age of sourcing cadavers in developing countries: a Nigerian survey

Throughout the history of medical science, the sourcing, storage, and management of cadavers for the study of gross anatomy have been problematic issues. As presented in this report, a study of these issues was conducted in the departments of anatomy of medical schools in Nigeria. To establish the extent and depth of the prevailing difficulties in the sourcing of cadavers, 18 (62.1%) of the Departments of Anatomy that qualified for this study were used. In sum, 94.4% of these schools reported an inadequate number of cadavers for study. The estimated ages of the cadavers were between 20 and 40 years and 85% of the schools reported more than 75% of the cadavers to be from the lower socioeconomic class. Altogether, 94.4% of the schools reported a male dominance of more than 95%. More than 72% of the schools reported that more than 90% of the cadavers were criminals that had been killed by shooting, less than 10% were unclaimed and unidentified corpses, and 0% originated from body bequest. No form of screening exercises for diseases and infective microorganisms was noted for all the schools, and there were no set standards for the acceptance or rejection of cadavers. Causative factors for the profile of available cadavers such as culture and religion were noted. This study was designed to look at various issues associated with the sourcing of cadavers for Anatomy education in typical developing African countries like Nigeria. As outlined in this report, the creation of legislation and the promotion and funding of programs highlighting the importance of body donation are crucial for improving the field of medical education.     

A Glimpse into the process of gaining permission for the educational dissection of human cadavers in the Ottoman empire

Dissection of the human body for educational purposes became officially permitted in the Ottoman Empire only after a long, difficult process. In the West, studies based on the findings of Galen had been taboo during a long period in which dissection of human bodies had been prohibited. Although the first dissection studies since ancient times began to appear in the Western literature in the late 13th and early 14th centuries, the post‐Galen taboo against dissection was broken only in the 16th century by the studies of Vesalius. However, in the Eastern World, it was only fairly recently that the idea of the “sanctity of the human body” could be challenged. In the medieval Islamic world, as during the Middle Ages in the West, prohibitions against the dissection of human cadavers continued for social and religious reasons, although the Koran does not specifically ban such dissection. This prohibition also continued through the Ottoman era, which began in the 14th century. The first efforts to end the prohibition on dissection in the Ottoman Empire were made at the beginning of the 19th century during the reign of Sultan Selim III but official permission for dissection was given only in 1841 during the reign of Sultan Abdulmecid. Educational dissections in the Ottoman Empire officially began at the Istanbul Medical School following the granting of this permission. This article will discuss the attempts to end the prohibition of dissection in Ottomans within the scope of the history of anatomical study in Turkey. Clin. Anat. 27:964–971, 2014. © 2014 Wiley Periodicals, Inc.     

Vertical distribution of formaldehyde concentration and simulated temperature and wind velocity from computational fluid dynamics in a gross anatomy laboratory

Cadavers for gross anatomy laboratories are typically embalmed in formaldehyde. Thus, medical students and instructors are exposed to formaldehyde vapors emitted from cadavers during dissection. In an attempt to improve the dissection environment, we examined indoor formaldehyde concentrations in a gross anatomy laboratory. Air samples were taken from 20, 110, 160, and 230 cm above the floor between dissection beds to represent areas near the floor, in the breathing zone of sitting students, in the breathing zone of standing students, and near the ceiling, respectively. Formaldehyde vapors were thoroughly diffused from the floor to the ceiling, suggesting that medical students are exposed to similar concentrations of formaldehyde based on distance from the floor. Computational fluid dynamics showed that cadavers are warmed by overhead fluorescent lights and the body heat of anatomy students, and indicated that the diffusion of formaldehyde vapors is increased by lighting and the body temperature of students. Computational fluid dynamics showed that gentle convection from anatomy students and cadavers carry formaldehyde vapors upward; downward flow near admission ports diffuse formaldehyde vapors from the ceiling to the floor in the anatomy laboratory.     

The study of anatomy in England from 1700 to the early 20th century

The study of anatomy in England during the 18th and 19th century has become infamous for bodysnatching from graveyards to provide a sufficient supply of cadavers. However, recent discoveries have improved our understanding of how and why anatomy was studied during the enlightenment, and allow us to see the context in which dissection of the human body took place. Excavations of infirmary burial grounds and medical school cemeteries, study of hospital archives, and analysis of the content of surviving anatomical collections in medical museums enables us to re-evaluate the field from a fresh perspective. The pathway from a death in poverty, sale of the corpse to body dealer, dissection by anatomist or medical student, and either the disposal and burial of the remains or preservation of teaching specimens that survive today in medical museums is a complex and fascinating one.     

Teaching anatomy with surgeons' tools: use of the laparoscope in clinical anatomy.

The purpose of this study was to establish the feasibility of laparoscopy in embalmed cadavers to teach abdominal gross anatomy. One cadaver was selected based on body habitus and absence of previous abdominal operations. A standard trocar was used to enter the abdomen at the umbilicus. Two trocars were placed in the left upper quadrant. Pneumoperitoneum was achieved with continuous CO(2) pressure. Liver retraction was achieved percutaneously, exposing the porta hepatis and the gallbladder. The dissection was done with four first-year medical students using standard laparoscopic equipment. Following this, the demonstration was projected over multiple monitors so that all students could participate. Laparoscopic dissection in an embalmed cadaver is feasible and an excellent educational tool for both the medical student and the dissector. The dissector has the opportunity to manipulate laparoscopic tools in a human model closely paralleling operative experience, and the students have an opportunity to learn abdominal anatomy from a clinical perspective. Laparoscopic examination and dissection of fresh cadavers has been used for training surgeons on new procedures such as colon resection, antireflux procedures, and cholecystectomy. There is no report of this same technology used in embalmed cadavers to teach basic anatomy. This approach allows first-year medical students to learn the anatomy while exposing them to the technology currently used in surgical practice, and it affords surgical residents and students additional opportunities to practice laparoscopic skills.     

Process of development of body donation law in Japan

In the world, throughout history it has been difficult to obtain bodies for cadaveric dissection practice and research. In Japan, the difficulties were enhanced by the unique social culture and understanding surrounding the deceased and family responsibility. Further, from the 1970's onward, there was a large influx of new medical schools. In order to provide such a large number of medical students with anatomical study materials which are not merely obtained from unknowing deceased, but rather willfully donated by the deceased, a means by which to officially donate bodies was necessary. From the mid-1970's anatomy professors and leaders of volunteer body donation organizations realized that there was a need to formulate a procedure for the wholesome development of a body donation law. Together, they proposed this concept to senators and then on to the Ministry of Education. Their efforts bore two fruits: creation (1982) of an Official Certificate of Appreciation from the Ministry of Education (addressed to the deceased and given to the family) and also the Body Donation Law (1983). For society, such a law ensures the cultural acceptance of the concept of body donation, because it proves verification by the government. Also, such a law resolves possible later disputes between family members. Further, this law can facilitate the true wishes of the deceased, not that of the family members. In 1995, the Crown Prince and Princess participated in the Ceremony of the Centenary of the Japanese Association of Anatomists. In his address, the Prince congratulated the Association for their leadership in the development of Japanese modern medicine. He noted that body donation has been a key point to facilitate excellent medical education. As a result of the body donation law, presently there is a sufficient number of donated bodies for student dissection practice at the medical schools throughout Japan. Certainly it is pleasing to all to know that the will of the deceased has been carried out. For the family as well as the schools, this process is undertaken in an official and socially acceptable manner. In this review, we describe the process toward the development of the body donation law and the influences of this law by quoting the official journal of the Japan Union of Voluntary Body Donation, "Tokushi Kentai" (Voluntary Body Donation).     

Attitudes of medical and dental students to dissection

Guy's, King's, and St. Thomas's School of Medicine encourages students to learn anatomy from human dissection. Today, there is a worldwide move of anatomy-based teaching away from dissection to prosection. This study investigates how attitudes toward dissection vary with gender and ethnicity. We assessed students' reactions and concerns regarding the dissecting room, any coping strategies they use to combat them, and analyzed effective methods of teaching anatomy to medical and dental students. Three questionnaires were distributed amongst 474 first-year medical and dental students before dissection and 1 week and 12 weeks after exposure to the dissecting room. Over the 3 months we found significant changes in the concerns of students about dissection. There were also significant differences (P < 0.05) between medical and dental students, males and females, and students of differing ethnic backgrounds, which persisted over 12 weeks. Both medical and dental students found tutorials and textbooks of most value in learning anatomy. Dental students found prosection more useful than medical students (P < 0.001) though neither group demonstrated a significant preference for prosection over dissection. Of concern, 7% reported recurring images of cadavers and 2% insomnia after commencing dissection. Interest in the subject matter and discussion were the commonest methods used to combat stress. This study contributes to the ongoing debate about the value of the dissecting room in the medical school curriculum.     

Attitudes of Turkish anatomists toward cadaver donation

There is an insufficient number of cadavers in anatomy education in Turkey. This is because of decreased number of unclaimed bodies and very few cadaver donations. Increasing the number of cadaver donation is one of the probable solutions. Although anatomists encourage people to donate bodies, the attitudes of anatomists toward donating their own bodies for dissection is not well known. In this study, the attitudes of Turkish anatomists toward cadaver donation were evaluated. The questionnaires were sent to the anatomists in Turkey by mail and E-mail. Eighty-three anatomists replied to the questionnaire. The main solutions proposed for cadaver insufficiency included increasing the supply of unclaimed bodies (77.1%) and increasing body donation (78.3%). Further, 51.8% of the respondents thought that increasing body donation was a long-term solution. The general belief (83.1%) was that a campaign would help to increase body donation and 47% of respondents were willing to participate in such a campaign. Of the 83 anatomists, 20.5% of the respondents donated their organs and 49.4% were planning to donate them. Further, 15.7% were planning to donate their bodies; however, 63.9% did not consider donating. The main reasons of the respondents to object the donation were: to be dissected by a colleague (15.7%), the unacceptability of donation by family (26.5%), psychological reasons (43.4%), the anxiety of disrespectful behavior to cadavers (26.5%), and religious beliefs (3.6%). Although the majority of the respondents objected to donating their bodies due to psychological reasons, body donation was proposed as the main solution of cadaver insufficiency.     

The poor, the Black, and the marginalized as the source of cadavers in United States anatomical education

When the practice of hands-on anatomical dissection became popular in United States medical education in the late 18th and early 19th centuries, demand for cadavers exceeded the supply. Slave bodies and thefts by grave robbers met this demand. Members of the public were aware that graves were being robbed and countered with various protective measures. Since the deterrence of grave robbing took time and money, those elements of society who were least economically and socially advantaged were the most vulnerable. Enslaved and free African Americans, immigrants, and the poor were frequently the target of grave robbing. The politically powerful tolerated this behavior except when it affected their own burial sites. Slave owners sold the bodies of their deceased chattel to medical schools for anatomic dissection. Stories of the "night doctors" buying and stealing bodies became part of African American folklore traditions. The physical and documentary evidence demonstrates the disproportionate use of the bodies of the poor, the Black, and the marginalized in furthering the medical education of white elites.     

Pathological analysis of cadavers for educational dissection by using postmortem imaging

This study was performed primarily to clarify whether pathological analysis of cadavers for anatomical dissection is possible using postmortem imaging (PMI), and whether this is worthwhile. A total of 33 cadavers that underwent systematic anatomical dissection at our medical school also underwent PMI. Fixative solution was injected into the corpus 3–4 days after death. PMI was then performed using an 8‐slice multi‐detector CT scanner 3 months before dissection. Before dissection, a conference was held to discuss the findings of the PMI. First, two radiologists read the postmortem images without any medical information and deduced the immediate cause of death. Then, the anatomy instructor revealed the medical information available. Based on this information, the radiologist, anatomy instructor, and pathologists suggested candidate sampling sites for pathological examination. On the last day of the dissection period, the pathologists resected the sample tissues and processed them for pathological examination. In 12 of 33 cases, the presumed causes of death could be determined based on PMI alone, and revision of the cause of death described in the death certificate was considered in five (15.2%) cases, based on PMI and pathological analysis. This article presents a novel method of pathological analysis of cadavers for anatomical dissection using PMI without disturbing the anatomy education of medical students.     

Infective agents in fixed human cadavers: a brief review and suggested guidelines

Cadavers remain a principal teaching tool for anatomists and medical educators teaching gross anatomy. Infectious pathogens in cadavers that present particular risks include Mycobacterium tuberculosis, hepatitis B and C, the AIDS virus HIV, and prions that cause transmissible spongiform encephalopathies such as Creutzfeldt-Jakob disease (CJD) and Gerstmann-Straussler-Scheinker syndrome (GSS). It is often claimed that fixatives are effective in inactivation of these agents. Unfortunately cadavers, even though they are fixed, may still pose infection hazards to those who handle them. Specific safety precautions are necessary to avoid accidental disease transmission from cadavers before and during dissection and to decontaminate the local environment afterward. In this brief review, we describe the infectious pathogens that can be detected in cadavers and suggest safety guidelines for the protection of all who handle cadavers against infectious hazards.     

Use of bequeathed and unclaimed bodies in the dissecting room

The bodies used in dissecting rooms have either been unclaimed or bequeathed. Although bequeathed bodies constitute the major source of bodies in many countries today, this is not a universal situation. The use of unclaimed bodies for dissection is traced historically from its origins in grave robbing and murder, and against the background of the thesis that it involves exploitation of the poor and the lack of informed consent. The ethical significance of the treatment of cadavers is considered in terms of the intrinsic and instrumental value ascribed to cadavers. The use of unclaimed bodies is assessed in relation to the ethical principles underpinning organ donation, including respect for the autonomy of the deceased, and the interests of family members, as well as reference to altruism as a basis of donations and the possible redemptive aspects of organ donations. It is argued that the use of unclaimed bodies does not correspond to any procedure we use today in the realm of organ donation. It is concluded that the use of unclaimed bodies is never to be the procedure of choice, since taking a body even for good purposes is ethically inferior to giving a body for the same purposes. Nevertheless, what is done with dead bodies for good reasons is not the most important of ethical matters, and a balance has to be attained between these ethical considerations and the potential benefits accruing to society. © 1994 Wiley-Liss, Inc.     

Plastination and its importance in teaching anatomy. Critical points for long-term preservation of human tissue

Most medical curricula rely on human bodies for teaching macroscopic anatomy. Over the past 20 years, plastination has become an important means of preservation of organs, for well dissected specimens or for body slices. Here, several critical points regarding body donation with legal and ethical considerations for long-term preservation, the use of cadavers in teaching and the preparation of plastinates as an additional teaching tool will be discussed. Silicone S10 is the gold standard in the preparation of plastinates. An important point to respect is the preparation of specimens, since only very well dissected body parts or excellent tissue sections should be plastinated to show the extraordinary aspects of the human anatomy. The preparation of thin and transparent sections and preservation with P40 polyester provides an additional technique to prepare resistant body slices. A selection of samples prepared by S10 and P40 are shown and compared. In addition, Prussian or Berlin blue staining of brain slices is shown to discriminate better between gray and white matter and demonstrate neuroanatomical structures. These plastinates have been used for many years in teaching first-and second-year medical students and have not lost their appeal. Students and staff appreciate the use of such plastinates. One of the advantages is that their use is not restricted to the dissection hall; slices and body parts can be used in any lecture room or in small group teaching. Therefore, ethical and legal questions need to be addressed regarding their specific use. Plastinates do not replace the traditional dissection courses, since students learn best the anatomical features of a given region by hands-on dissection and by exploratory anatomy. Furthermore, plastinates are more rigid and do not allow demonstration of hidden structures; they also become more cumbersome for endoscopy or are too rigid for demonstrating mechanical features of joints. However, although not a replacement for traditional dissections, plastination provides an additional tool for long-term preservation and for teaching human anatomy.     

From formalin to thiel embalming: What changes? One anatomy department's experiences

In 2009, the Centre for Anatomy and Human Identification started Thiel embalming on a small scale to assess (i) the suitability for our current teaching in which long‐lasting dissection courses are key, (ii) the potential for new collaborations and activities, and (iii) the practical implications of changing our embalming method from formalin to Thiel. Twenty six Thiel‐embalmed cadavers have been used for dissection by staff and students on a taught MSc course, as a model for clinical and surgical training, and increasingly as a model for evaluation of new medical devices and procedures. Our experiences with dissection were mostly positive especially for teaching the musculoskeletal system. Internal organs handle differently from formalin‐fixed organs and dissection manuals need to be adjusted to reflect this. Durability of the cadavers was not an issue, though changes are seen over time due to gradual fluid loss. We have started new collaborations related to postgraduate anatomy teaching and advanced training in surgical and clinical skills. In general, feedback is very positive and demand for cadavers outstrips our current limited supply. Thiel‐embalmed cadavers were found to provide a unique opportunity for evaluation of medical products especially in areas where no suitable alternative model is available, and without the complications associated with clinical testing. This has resulted in new collaborations and research projects. As a result Thiel‐embalmed cadavers are used for longer and for more activities than formalin cadavers: this requires changes in our procedures and staff roles. Clin. Anat. 26:564–571, 2013. © 2013 Wiley Periodicals, Inc.     

Attitudes to anatomy dissection in an Irish medical school

Many studies around the world have looked at the stresses placed on medical students by cadaveric dissection. Although these studies have linked the use of cadavers in medical teaching to stress, some investigations have suggested an association with severe psychological stress and even post‐traumatic stress disorder. This study assessed the attitudes of medical and biomedical sciences students in an Irish medical school towards cadaveric dissection by recording, through a questionnaire, their perceptions and experience before initial exposure to dissection and subsequently examining their attitudes after the first dissection and after 9 weeks. Student attitudes towards the dissecting room remained consistently positive for the duration of the study with only a minority of respondents reporting negative symptoms. Pre‐existing attitudes to the idea of dissection were unaffected by exposure and subsequent continuous experience of dissection. The majority of students in this study did not find the dissecting room experience stressful, and considered time spent in the dissecting room valuable. However, the proportion of students with negative experiences in the dissecting room was higher than has been reported in previous studies. Many respondents felt they could be better prepared for the dissecting room experience, indicating an increasing requirement for effective preparatory programmes. Clin. Anat. 22:386–391, 2009. © 2009 Wiley‐Liss, Inc.