Without exception, the only people who checked themselves in at teaching hospitals were those too poor to pay for private surgery. In return for an operation that was as likely to kill them as make them better—bladder stone removal had a mortality rate of 50 percent—the poor basically donated themselves as living practice material. Not only were the surgeons unskilled, but many of the operations being done were purely experimental—no one really expected them to help. Wrote historian Ruth Richardson in Death, Dissection, and the Destitute, “The benefit [to the patient] was often incidental to the experiment.”
With the advent of anesthesia, patients were at least unconscious while the young resident tried his hand at a new procedure. But they probably didn’t give their permission for a trainee to take the helm. In the heady days before consent forms and drop-of-a-hat lawsuits, patients didn’t realize what they might be in for if they underwent surgery at a teaching hospital, and doctors took advantage of this fact. While a patient was under, a surgeon might invite a student to practice an appendectomy.
Never mind that the patient didn’t have appendicitis. One of the more common transgressions was the gratuitous pelvic exam. A budding M.D.’s first Pap smear—the subject of significant anxiety and dread-—was often administered to an unconscious female surgical patient. (Nowadays, enlightened medical schools will hire a “pelvic educator,” a sort of professional vagina who allows the students to practice on her and offers personalized feedback and is, in my book anyway, a nominee for sainthood.)
Gratuitous medical procedures happen far less than they used to, owing to the public’s growing awareness. “Patients are savvier these days, and the climate has changed a great deal,” Hugh Patterson, who runs the willed body program at the University of California, San Francisco, Medical School, told me. “Even at a teaching hospital, patients request that residents not do the surgery. They want to be assured the attending does the procedure. It makes training very difficult.”
Patterson would like to see specialized cadaver anatomy labs added to third- and fourth-year programs—instead of teaching anatomy only in the first year, “as one big bolus.” Already, he and his colleagues have added a focused dissection, similar to the facial anatomy lab I’m observing today, to the curricula of surgical subspecialties. They’ve also set up a series of sessions at the medical school morgue to teach emergency room procedures to third-year students. Before a cadaver is embalmed and delivered to the anatomy lab, it may pass an afternoon getting tracheal intubations and catheterizations. (Some schools use anesthetized dogs for this purpose.) Given the urgency and difficulty of certain ER procedures, it makes good sense to practice them first on the dead. In the past, this has been done in a less formal manner, on freshly dead hospital patients, without consent—a practice whose propriety is intermittently debated in hushed meetings of the American Medical Association. They should probably just ask for permission: According to one New England Journal of Medicine study on the subject, 73 percent of parents of newly dead children, when asked, gave consent to use their child’s body for teaching intubation skills.
I ask Marilena if she plans to donate her remains. I have always assumed that a sense of reciprocity prompts doctors to donate— repayment for the generosity of the people they dissected in medical school. Marilena, for one, isn’t going to. She cites a lack of respect. It surprises me to hear her say this. As far as I can tell, the heads are being treated with respect. I hear no joking or laughter or callous comments. If there can be a respectful way to “deglove” a face, if loosening the skin of someone’s forehead and flipping it back over his or her eyes can be a respectful act, then I think these people are managing it. It’s strictly business.
It turns out that what Marilena objected to was a couple of the surgeons’ taking photographs of their cadaver heads. When you take a photograph of a patient for a medical journal, she points out, you have the patient sign a release. The dead can’t refuse to sign releases, but that doesn’t mean they wouldn’t want to. This is why cadavers in photographs in pathology and forensics journals have black bars over their eyes, like women on the Dos and Don’ts pages of Glamour. You have to assume that people don’t want to be photographed dead and dismembered, any more than they want to be photographed naked in the shower or asleep on a plane with their mouth hanging open.
Most doctors aren’t worried about a lack of respect from other doctors.
Most of the ones I’ve spoken to would worry, if anything, about a lack of respect from students in the first-year gross anatomy lab—my next stop.
The seminar is nearly over. The video monitors are blank and the surgeons are cleaning up and filing out into the hallway. Marilena replaces the white cloth on her cadaver’s face; about half the surgeons do this. She is conscientiously respectful. When I asked her why the eyes of the dead woman had no pupils, she did not answer, but reached up and closed the eyelids. As she slides back her chair, she looks down at the benapkined form and says, “May she rest in peace.” I hear it as “pieces,” but that’s just me.
2. CRIMES OF ANATOMY
Body Snatching and Other Sordid Tales from the Dawn of Human Dissection
Enough years have passed since the use of Pachelbel’s Canon in a fabric softener commercial that the music again sounds pure and sweetly sad to me. It’s a good choice for a memorial service, a classic and effective choice, for the men and women gathered (here today) have fallen silent and somber with the music’s start.
Noticeably absent amid the flowers and candles is the casket displaying the deceased. This would have been logistically challenging, as all twenty-some corpses have been reduced to neatly sawed segments—hemisections of pelvis and bisected heads, the secret turnings of their sinus cavities revealed like Ant Farm tunnels. This is a memorial service for the unnamed cadavers of the University of California, San Francisco, Medical School Class of 2004 gross anatomy lab. An open-casket ceremony would not have been especially horrifying for the guests here today, for they have not only seen the deceased in their many and various pieces, but have handled them and are in fact the reason they have been dismembered. They are the anatomy lab students.
This is no token ceremony. It is a sincere and voluntarily attended event, lasting nearly three hours and featuring thirteen student tributes, including an a capella rendition of Green Day’s “Time of Your Life,” the reading of an uncharacteristically downbeat Beatrix Potter tale about a dying badger, and a folk ballad about a woman named Daisy who is reincarnated as a medical student whose gross anatomy cadaver turns out to be himself in a former life, i.e., Daisy. One young woman’s tribute describes unwrapping her cadaver’s hands and being brought up short by the realization that the nails were painted pink. “The pictures in the anatomy atlas did not show nail polish,” she wrote. “Did you choose the color?… Did you think that I would see it?… I wanted to tell you about the inside of your hands… I want you to know you are always there when I see patients. When I palpate an abdomen, yours are the organs I imagine. When I listen to a heart, I recall holding your heart.” It is one of the most touching pieces of writing I’ve ever heard. Others must feel the same; there isn’t an anhydrous lacrimal gland in the house.