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EDUCATION

The dissection course – necessary andindispensable for teaching anatomy tomedical students

Horst-Werner Korfa, Helmut Wichta, Robert L. Snipesb,Jean-Pierre Timmermansc, Friedrich Paulsend,Gabriele Runee, Eveline Baumgart-Vogtb,�,1

aDr. Senckenbergische Anatomie, Institute for Anatomy II, Johann Wolfgang Goethe University of Frankfurt,Frankfurt am Main, GermanybInstitute for Anatomy and Cell Biology II, Justus Liebig University of Giessen, Aulweg 123,35385 Giessen, Hessen, GermanycLaboratory of Cell Biology and Histology, Department of Veterinary Sciences, University of Antwerp, Antwerp, BelgiumdDepartment of Anatomy and Cell Biology, University of Halle-Wittenberg, Halle, GermanyeDepartment of Anatomy I, Cellular Neurobiology, University of Hamburg, Hamburg, Germany

Received 14 August 2007; received in revised form 6 October 2007; accepted 7 October 2007

KEYWORDSMedical education;Anatomicaleducation;Dissection course;Plastination

ee front matter & 2007aanat.2007.10.001

ing author. Tel.: +49 641ess: Eveline.Baumgart-V.med.uni-giessen.de/an

SummaryAnatomy is a major basic subject in medicine and related biomedical sciences. Acentral tool most universities use for teaching anatomy is the ‘‘dissection course’’, inwhich medical students learn the basic constructional principles of the human bodyby dissecting a cadaver. In recent years, the relevance and value of the dissectionlaboratory have been under discussion at different universities due to high costs andproblems of shortness in time in some medical curricula. Indeed, during the last 10years, several universities in the US and the UK have abandoned dissection and havemoved from a cadaver-oriented to a cadaverless anatomy. This development resultsin a fundamental discussion on the role of the ‘‘dissection course’’ in the medicalcurriculum, ultimately raising the question as to whether we should continueteaching anatomy by dissection. This article presents nine arguments for thedissection course as a central tool for teaching macroscopic anatomy and is anattestment to the continuation of the use of cadaver material in anatomicallaboratories within the auspices of scholastic and university order for the benefit offuture physicians with due respect and honour guaranteed for every donor.& 2007 Published by Elsevier GmbH.

Published by Elsevier GmbH.

99 47101/47100; fax: +49 641 99 47109.ogt@anatomie.med.uni-giessen.de (E. Baumgart-Vogt).at/

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practice of cadaver use in anatomical institutes has

Introduction

Anatomy, the science of human biology, is amajor basic discipline every student or professionalhas to learn when entering medicine or biomedicalsciences.

Scientific anatomy can be traced back tothe world famous publication of Vesalius’ ‘‘Dehumani corporis fabrica libri septem’’ (Basel,1543) (Figure 1).

Anatomical dissection became an integral part ofthe medical curriculum in the 1800s in the form of‘‘prosection’’ (Enke, 2005). Over the centuries, the

Fig. 1. Cover of book one ‘‘De humani coporis fabrica libri secomplete book, see Garrison et al. (2003), http://vesalius.Daniel H. Garrison, Department of Classics, Weinberg CollegeIL, USA.

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evolved from a historical public spectacle, ‘‘Anato-mia publica’’, to modern educational anatomicaldissection based on donor programmes. Duringtheir lifetime, potential donors release their bodyafter death for purposes of research and educationas set down in a legally binding and securetestament, leading to reverent security of donorassurance.

The reverence and honour offered the donor isoften reflected today in an interconfessionalecumenical funeral service not only attended bystudents of the anatomy lab but also planned and

ptem’’, Basel, 1543. For an annotated translation of thenorthwestern.edu/. Publication with permission of Prof.of Arts and Sciences, Northwestern University, Chicago,

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carried out with musical accompaniment andceremonial attestation (Pabst and Pabst, 2006).

With the advent of new techniques and computerscience, alternative methods of teaching anatomycame into existence. With their refinement and theubiquity of websites and widespread availability ofcomputer programs to almost all medical students,an alternative concept of teaching anatomy arose:‘‘the cadaverless gross anatomy lab’’. This trendwas strengthened by inherent rampant curriculumchanges paying tribute to scientific advances due tothe increase in manageable knowledge in cellularand molecular biology and genetics to be taught tomedical students. Since teaching gross anatomy ina dissection course for students is costly andmedical faculties suffer from financial constraints,a debate has thus ensued: cadaver versus cadaver-less anatomy teaching (Aziz et al., 2002; Arraez-Aybar et al., 2004; Granger, 2004; Guttmann et al.,2004; McLachlan, 2004; Pawlina and Lachman,2004; Topp, 2004; Vazquez et al., 2005; Biasuttoet al., 2006; Winkelmann, 2007; IFD-Internet ForumDiscussion, 2006).

The following thesis will be an attestation to thecontinuation of the use of cadaver material inanatomical labs within the auspices of scholasticand university order for the benefit of futurephysicians with due respect and honour guaranteedfor every donor. Moreover, it will set forth ninetenets against the sole use of plastinized cadavericmaterial and the sole use of models and/orcomputers in place of fixed cadavers as hasrecently taken place in some parts of the academicworld. The subsequent argumentation is a strongplea for continuation of the cadaver-centreddissection course as an integral and indispensablecomponent of the classical dissection labs forteaching anatomy.

Nine arguments for the dissection courseas the core of gross anatomy education

The practical argument

In current medical education much attention ispaid to passive analyses, to impersonal acquisitionof knowledge and to diagnostics and therapieswithout any direct bodily contact. However, ‘‘med-icine’’ is an art that inter alia requires manualskills. Doctors not only analyse, they also act, andwhen doing so, they use their hands, be it as asurgeon or as a general practitioner, be it with ascalpel or with a laryngoscope. The art of ‘touch-ing’ patients’ bodies as performed by physicians is

naturally entirely different from everyday contactin that doctors’ touchings are analytical andinstrumental, or part of operations or surgicalinterventions. The gross anatomy lab offers theunique possibility to learn and practice manualskills required for analytical ‘‘doctoral touching’’.

Plastinates and ‘body slices’ do not fulfil theserequirements, since they do not allow such contactand practical training.

The argument of hypothetical seeing andthinking

According to Karl Popper knowledge acquisitionoccurs via testing and falsification of hypotheses(Popper, 1959). Indeed, the doctor’s diagnosticview on his/her patient is not only analytical.Doctors diagnose by putting forward hypothesesand evaluating them. The range of diagnostic andtherapeutic tools will depend on this hypothesizingprocess of observing and thinking. The dissectioncourse can be seen as a preparation to thisprofoundly medical and scientific view of man andthe world. Students equipped with dissectionscalpels and forceps not only see, they also think(well, ideally at least): ‘‘When I cut at this site, Inormally should see this or that’’. If such is thecase, then you have learned something. If some-thing unexpected emerges, then you have alsolearned something. Unlike the living body, acadaver does not punish errors. In contrast, theseerrors may even lead to deeper insight.

Plastinates or anatomical models, on the otherhand, do not allow such a way of thinking andhypothetical deductionism.

The didactic/constructive argument

According to Theodor W. Adorno ‘‘A man ofscience knows the nature of things insofar as he isable to construct them’’ (Horkheimer and Adorno,1971). It stands to reason that passive acquisition ofknowledge (reading, hearing, observing) is far lessefficient than active acquisition of knowledge(acting, discussing, constructing). Dissecting canbe seen as acting, or even better, as organizedacting in groups. Dissecting strategies should beplanned; step-by-step actions should be discussedin advance and – last but not least – the anatomyshould be re/constructed after the dissection. Therelatively soft, pliable cadaveric material used inthe dissection course is not just dismembered, it isdissected in such a way that it can be put backtogether again. Indeed, there is nothing moreinformative and useful than trying to reconstruct

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the dissected convolutes of the guts and abdominalorgans back to their original positions.

Plastinates or models, however, are rigid struc-tures that do not or at least only partially permitde/reconstruction.

The educational psychological argument

Knowledge acquisition is most efficient wheninvolving as many senses as possible. It is thereforemost expedient from an educational psychologicalpoint of view to bring in as many contextual sensoryimpressions as possible into educational processes.This approach is fully warranted in the case of adissection course, during which students mustactivate all senses to literally comprehend. In thisrespect, dissection courses serve as a unique,powerful tool to convey macroscopic knowledge.

Glossy presentations and plastinates may serve asshort-term ‘‘edutainment’’ (education+entertain-ment ¼ edutainment) but do not engrave the basicconcepts of anatomy into the long-term memory ofstudents.

The philosophical/medical argument ofdistance and proximity

Being a physician implies occupying a position inthe tug of war between subject and object in a veryspecific way. In a sense, patients should beregarded as the ‘object among objects’ and thedoctor’s objective view should result in sound,useful diagnoses and valid therapies. Obviouslyphysicians also deal with patients, who should beconsidered not only as objects but also as humanbeings and hence subjects, whom doctors shouldrespect and understand as such. One of the mostimportant qualities of a good physician is the way inwhich (s)he is able to combine both roles, i.e. thatof neutral observer and that of compassionatehelper.

The extent to which students are successful inthis dual role will be disclosed for the first time inthe dissection course. The first arduous steprequired of students in dissection courses is thecold objectivism of the cadaver, which may still beseen as an individual, sometimes even with apersonality. The cadaver, the specimen, should beconverted into an ‘object’, an object amongobjects in the students’ minds. Only then can itbe dissected.

In the next – and still more difficult – step, this‘object’, while gradually losing its original formduring the dissection process, should begin to tellthe story of the human being to whom it belonged.

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The fragility of bones may point to the painfulprocess of osteoporosis, the fine-spun muscles to abedridden history, the calcified coronary arteries toinfarctiony.

At the end of the course, the objects, thespecimens, the cadaver, the donors regain theirnames and the status of being a subject. They arecremated in a personal way. Many medical facultiesin Germany organize central memorial ceremoniesfor the donors, whose urns are personally carried totheir graves by the students themselves.

Any degree of mastering such attitudes, whichare indispensable for practising in the medicalprofession, is impossible when working with plasti-nates, which will remain objects among objects andwhich only serve purely illustrative functions.

The argument of stereotypy

According to Nietzsche (1880), man is a ‘divi-duum’ and hence divisible, an opinion that iscertainly true from an anatomical point of view.Every human being – everyone who is reading thistext – is, however, also an ‘in-dividuum’, i.e.,divisible but at the same time unique. Thisuniqueness, which the patient wishes to seerespected by his/her doctor – and quite rightly so– also pertains to physical properties. Differencesexist and differences do matter. An example: thefact that no pulse is felt at the usual location on thewrist does not necessarily mean that the patient isdead – the artery in the hand might rather follow adifferent course. Each year, teachers and studentswill experience the very cosmos of diversity basedon a universal, common constructional plan, andthis in the same surprising and unexpected indivi-duality of a patient that is revealed in front of thephysician. This feeling of surprise at the identifica-tion of such a variation during the dissection courseis a highly informative and enriching experience,for those who can be proud of discovering it, forthose who have identified it and for those who tryto explain it. The decisive element, just like in reallife, lies in the momentary effect of surprise aboutindividuality and the way of dealing with it –

flexibility when dealing with something that de-viates from the rule. These aspects are trained in agross anatomy course.

A series of plastinates, even one showing themost common variations, quickly loses its novelcharacter. Accordingly, teachers tire of the sameidentical variants and students quickly know the listof exposed variations by heart. The ‘individuum’returns to the status of ‘dividuum’: a heap ofknown, exchangeable components.

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The argument of ‘connective tissue’

Plastinates or anatomical models are final pro-ducts and miss a vital aspect of the human body.There is hardly any organ that ‘‘appears just likethat’’. Instead, organs need to be laboriously andelaborately uncovered before being removed,excised and cut out of connective tissue envelopes,fasciae and adipose tissue. Many of the seeminglywell-delineated entities in anatomy (e.g., thecollateral bands of joint capsules) appear asartificially created units: in reality, they are‘nothing more’ than distinct regions within the con-nective tissue continuum of, e.g., a joint capsule.They are created by means of a scalpel. Otherorgans, however (e.g., lungs or cruciate liga-ments), indeed just ‘appear in a clearly delineatedway’ as one further explores the cavities in whichthey lie.

Plastinates do not afford this experience to theobserver: all structures are immediately exposed.The difference between ‘production’ and ‘discov-ery’ is denied.

Yet it is this connective tissue, these tough orfragile areas, these clefts and separating walls, inwhich nerves and blood vessels are contained thatform the very essence of a surgeon’s skills. It isthrough this connective tissue – and not throughthe organs proper – that (s)he clears a path to theorgan of interest. In addition, connective tissue isthe area through which pathological processesinvade the organism and the area through whichthe major body pathways run from one region toanother. Connective tissue both connects andseparates, joins and partitions the organism. Theskilful, mechanical and topographical approachto this tissue is a prerequisite to gaining insightinto anatomy. To prospective surgeons it is evenmore essential: only during the dissection courseare the necessary skills developed to deal withthis important component of the human body(connective tissue).

Once again, plastinates or models conceal thisprocess of dealing with connective tissue. Inaddition, the totally different consistency of thevarious tissues is reduced to sheer uniformity.

The argument against the ‘plastinateauthenticity’

Eighty percent of the human body is comprised ofwater and fat. The dissection course specimens stillpossess these essential parts of our being. Inplastinates, however, these 80% are replaced bysynthetic material, leading to the loss of authen-

ticity. Equally unreal are the misleading colours ofplastinates, which indeed are painted vividly.Authentic colours and the state of the organsurfaces are not exposed by this technique or thatmethod. Body surfaces (mat, fibrous, velutinous orsparkling) are visualized far better by means ofconservation methods that do not mask fat orwater.

The argument of the life of knowledge

Admittedly, gross anatomy is no longer about newdiscoveries, but rather about reproduction ofknowledge gleaned over centuries. Nevertheless,the following premise holds true for anatomists (aswell as for anyone reading this text): collectedknowledge is not equal to reproducible knowledgeand skills. You may have learned at school how tosolve a differential equation and perhaps evenknow where to look it up again; however, you willmost probably not find the solution unless differ-ential equations are your daily activity. Or else: youhave lost the procedural knowledge of solving theequation.

Knowledge does not live in books, it lives in themind. It does not only survive by production butalso – and mainly – by reproduction. Whatever isknown and written down somewhere, but is nolonger practised, is useless. Production and repro-duction of knowledge in dissection courses, how-ever, will help to conserve and save practisedknowledge, and therefore be beneficial also forfuture generations of physicians.

Conclusion

This article reinforces the central role of thedissection course in medical education by means ofnine subjectively selected arguments. The neces-sity to maintain ‘hands-on’ cadaver dissection (orto re-establish it in those medical faculties thatabandoned it in the last few years) is also evi-dent from several other recent publications. Thus,in his critical review on the role and quality ofanatomy teaching in the UK, A. Raftery, ConsultantGeneral Surgeon at the Northern General HospitalSheffield, has emphasized the need for a corecurriculum that provides an anatomical basis forpatient examination and has listed the benefitsof dissection according to Professor Harold Ellis,London: ‘‘Dissection teaches the basic languageof medicine and some manual dexterity. It intro-duces an understanding of three-dimensional anat-omy and the concept of biological variation. It

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introduces students to team working and fosterscommunication skills between individual studentsand groups. It acclimatizes students to the realityof death and teaches respect for the body’’. Similarconclusions were drawn by Rizzolo and Stewart(2006) who state that ‘‘problem-solving in thedissection laboratory develops the habit-of-mindsof clinical practicey, relating dissection to ima-ging modalities develops the spatial reasoning skillsneeded to understand computer simulationsy.’’and ‘‘the human face of dissection fosters self-reflection and integration of the cognitive andaffective skills required for medial practice’’.The value of the classical approach to teachinganatomy in medical education was emphasizedin a retrospective evaluation by 1029 medicaldoctors who applied for their specialist exami-nation at the Medical Council of North-Rhine,Germany, in 2002 and 2003 (Hofer et al., 2006).Similar observations were made in another stateof Germany (‘‘Niedersachsen’’) where candidatesof the specialist examination were asked toretrospectively evaluate the importance of thedisciplines and classes taught in the medicalcurriculum: anatomy was ranked to be of equallyhigh importance as internal medicine (Pabst andRothkotter, 1996).

A synoptic view of all available evaluations andarguments makes a strong case for keeping cadaverdissection as an essential part of medical educationand as an indispensable basis for other educationalapproaches, such as living anatomy, seminars onclinical aspects, problem-oriented learning, as wellas anatomical and computed modalities. We asprofessional anatomists should support humancadaveric anatomy as a superior tool to achieveanatomical knowledge.

Acknowledgement

We thank Phillip Grant for carefully readingthe manuscript and for English corrections. Inaddition, we are deeply indebted to Prof. DanielH. Garrison for providing the electronic file of thecover picture of ‘‘De humani corporis fabrica libriseptem’’.

Contact address: D-Garrison@northwestern.edu,Department of Classics, Weinberg College of Artsand Sciences, Kresge Hall, 1-540, 1880 CampusDrive, Northwestern University, Chicago, IL, USA.http://www.cas.northwestern.edu/classics/faculty/garrison/garrison.htm

For more information on Vesalius see also http://www.cas.northwestern.edu/classics/faculty/garrison/vesalius.htm

References

Arraez-Aybar, L.A., Castano-Collado, G., Casado-Morales,M.I., 2004. Dissection from the Spanish anatomist’sperspective: aims, attitudes and related aspects.Anat. Rec. (New Anat.) 1281B, 15–20.

Aziz, M.A., McKenzie, J.C., Wilson, J.S., Cowie, R.J.,Ayeni, S.A., Dunn, B.K., 2002. The human cadaver inthe age of biomedical informatics. Anat. Rec. (NewAnat.) 269, 20–32.

Biasutto, S.N., Caussa, L.C., Criado del Rio, L.E., 2006.Teaching anatomy: cadavers vs computers. Ann. Anat.188, 187–190.

Enke, U., 2005. Historische Anmerkungen zu Anatomieund anatomischem Unterricht an den hessischenUniversitaten von 16. bis zum 18. Jahrhundert. Hess.Arztebl. 122, 819–824.

Garrison, D.H., Hast, M., Northwestern University, 2003.On the Fabric of the Human Body. An annotatedtranslation of the 1543 and 1555 editions of AndreasVesalius’ De Humani Corporis Fabrica, Book One,March 19, 2003, Northwestern University, Evanston,IL, USA /http://vesalius.northwestern.edu/S.

Granger, N.A., 2004. Dissection laboratory is vital tomedical gross anatomy education. Anat. Rec. (NewAnat.) 281B, 6–8.

Guttmann, G.D., Drake, R.L., Trelease, R.B., 2004. Towhat extent is cadaver dissection necessary to learnmedical gross anatomy? A debate forum. Anat. Rec.(New Anat.) 281B, 2–3.

Hofer, M., Jansen, M., Soboll, S., 2006. Verbesserung-spotential des Medizinstudiums aus retrospektiverSicht von Facharztpruflingen. Dtsch. Med. Wo-chenschr. 131, 373–378.

Horkheimer, M., Adorno, T.W., 1971. Dialektik derAufklarung. Fischer, Frankfurt.

IFD-Internet Forum Discussion, 2006. Listserv of theAmerican Association of Clinical Anatomists, someparticipants: Cleary, L. (University of Texas, HSCHouston, USA); Guttmann, G. (Peninsula MedicalSchool, Plymouth, UK); Hirsch, B.E. (Drexel UniversityCollege of Medicine, Philadelphia, USA); Johnson, I.(University College, London, UK); Rizzolo, L. (YaleUniversity, New Haven, USA); Seyfer, A. (Walter ReedMedical Center Washington, DC, USA); Snipes, R.(University of Giessen, Giessen, Germany); Winkel-mann, A. (Charite, Berlin, Germany); Witmer, M. (OhioState University, Columbus, USA).

McLachlan, J.C., 2004. New path for teaching anatomy:living anatomy and medical imaging vs. dissection.Anat. Rec. (New Anat.) 281B, 4–5.

Nietzsche, F., 1880. Menschliches, Allzumenschliches. EinBuch fur freie Geister. In: Friedrich Nietzsche,Gesammelte Werke (2005). Gondrom-Verlag, Bin-dlach.

Pabst, R., Rothkotter, H-J., 1996. Befragung in Hannover.Was Arzte ruckblickend von ihrer Ausbildung halten.Dtsch. Artzebl. 93, A451–A452.

Pabst, V.C., Pabst, R., 2006. Danken und Gedenkenam Ende des Praparierkurses. Dtsch. Arztebl. 103,A3008–A3010.

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Pawlina, W., Lachman, N., 2004. Dissection in learningand teaching gross anatomy: rebuttal to McLachlan.Anat. Rec. (New Anat.) 281B, 9–11.

Popper, R.K., 1959. The Logic of Scientific Discovery.Basic Books, New York.

Raftery, A.T., 2007. Anatomy teaching in the UK. Surgery25, 1–2.

Rizzolo, L.J., Stewart, W.B., 2006. Should we continueteaching anatomy by dissection wheny? Anat. Rec.289B, 215–218.

Topp, K.S., 2004. Prosection vs dissection, the debatecontinues: rebuttal to Granger. Anat. Rec. (New Anat.)281B, 12–14.

Vazquez, R., Riesco, J.M., Carretero, J., 2005. Reflec-tions and challenges in the teaching of humananatomy at the beginning of the 21st century. Eur. J.Anat. 9, 111–115.

Vesalius, A., 1543. De humani corporis fabrica libriseptem/Andreae Vesalii (Basel, first ed. 1543,second ed., 1555). Galter Health Sciences Library,Special Collections, Northwestern University, Chicago,USA.

Winkelmann, A., 2007. Anatomical dissection as ateaching method in medical school – a review of theevidence. Med. Educ. 41, 15–22.