Book Review |
The good is oft interred with their bones
Two recent publications describe anatomical dissection in the 19th century and how in Great Britain the 1832 Anatomy Act regulated anatomical dissection. A current exhibition portrays the history of human anatomical dissection, the trade of grave robbing and murder to supply bodies for the tuition of anatomy in Scotland, and the enactment of the Anatomy Act 1832. The most complete versions of the exhibition will be on view in Edinburgh and Glasgow and smaller collections will be exhibited in other medical centres in Scotland (Patrizio and Kemp, 2006
; Barnes and French, 2006). The two publications relating to this exhibition illustrate many of the items on display and describe in detail the history of anatomical dissection and the teaching of this subject in Scotland.
Mark Twain's Tom Sawyer observed grave robbing in North America and the recounting of these and other abuses has been the subject of many publications (Richardson, 1988, 2001; Hughes, 2003). In a recent account, Helen MacDonald has described anatomical practice in 19th century Australia, where bodies of convicted felons were readily available as were those of aborigines and poor persons dying in hospitals. Her extensive researches importantly review the practice of anatomical dissection in a penal colony (MacDonald, 2005). These two accounts join many others in denouncing the early anatomical dissectors and their disregard for the sanctity of the body after death.
The many publications describing the scandals of anatomical dissection seldom emphasize the benefits of anatomical knowledge so patiently acquired over centuries. And whilst the 1832 Act regulated and assisted human anatomical dissection, the complexity of the Human Tissue Act 2004 will restrict the performance of necropsies and hinder pathology research especially of diseases of the brain.
History of anatomy
Modern anatomical teaching began in Bologna, when Mondinus (Mondino de’Luzzi, 1270–1326) began public human dissections in 1315 (Castiglioni, 1941). His textbook of anatomical dissection—the Anatomia—first printed in Padua in 1478, was used for centuries in over 40 editions. Mondinus was followed by Berengario da Carpi (1460–1530) and Alexandro Achillini (1463–1512), who moved from Bologna to Padua, beginning Padua's pre-eminence in the teaching of anatomy. About 1539, a young Cambridge graduate—John Caius (1510–1573) of Norwich—came to Padua as Professor of Greek and after lodging with the great Andreas Vesalius (1514–1564), turned his attention to medicine and anatomy, graduating MD at Padua in 1541. On his return in 1547, Caius taught modern anatomy at the Barber-Surgeons Hall, London, and at Cambridge. In 1565, the bodies of two executed criminals were made available to Caius College, for dissection by the Regius Professor of Physic. Anatomy tuition was conducted at the colleges and only later provided by the university. The anatomy theatre at Cambridge dates from 1689 and the chair of anatomy was created in 1707. Modern anatomy began in the 16th century, but the great expansion of the subject took place in the 17th century; in England in London, Oxford and Cambridge. But an accurate description of the brain, and the recognition of three nervous systems, central, peripheral and autonomic, awaited an anatomist in this specialized field and required someone with a vision comparable to that of the great Vesalius. Such an individual arose in Oxford: his name was Thomas Willis (1621–1675; Hughes, 1991).
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Thomas Willis
Willis lived most of his life in Oxford. He was taught classics at school in The High, and studied at the College of Christ Church, where he gained his Bachelor of Arts. The English Civil Wars disrupted his university education and diverted his studies from theology to medicine. Encouraged by the Regius Professor of Medicine, his medical studies were replaced by service in the Royalist Army in Oxford and consequently he was spared the usual readings of Galen and Aristotle, then comprising academic instruction in medicine. His BM, awarded in 1646, at the close of the Civil War, was a tribute to his military service rather than an award for his academic studies. A royalist, Willis endured the Protectorate of Oliver Cromwell, but the restoration of Charles II in 1660 changed his fortunes. The memory of Willis's service in the Civil War lingered and Charles commanded his appointment to the Oxford Chair of Natural Philosophy, a significant step for world medicine. Willis lectured not on philosophy but on observations arising from his medical practice. In addition to medicine, he taught anatomy, physiology, psychology, chemistry and pharmacy. John Locke attended Willis's lectures and his notes have been translated and published (Dewhurst, 1980). From these lectures arose three textbooks in neuroscience: Cerebri Anatome on anatomy, Pathologiae Cerebri on pathology and De Anime Brutorum on function. Interspersed in these three books and four other publications were reports of his cases and necropsies, with observations on anatomy, physiology and pathology, and descriptions of diseases and syndromes. In these Latin texts lie many original observations.
Willis made many discoveries in neuroanatomy. His were the first descriptions of the nervus ophthalmicus Willisii, the nervus accessorium Willisii and the chordae Willisii (trabeculae which traverse the meningeal sinuses). In anatomical dissections, he distinguished the sympathetic from the wandering (vagal) nerves, showing how both innervate the heart and arteries. His ligation of the vagi in a dog, producing cardiac irregularity, begins the physiological study of cardiac innervation. Willis was the first to describe and illustrate the brain from direct accurate observation and his names persist, for example, the cerebral peduncles and the medullary pyramids. He described and illustrated the internal capsules and, in patients with long standing hemiplegia, provided the first description of unilateral capsular atrophy due to cortico-spinal tract degeneration. This was the first description of tract degeneration in the nervous system. Willis described and named the anterior commissure, the stria terminalis, the inferior olives and the claustrum. His dissections of the spinal cord remarked on its complicated blood supply. In his descriptions of the cranial and spinal nerve roots, Willis used the Greek word for ‘sinew’ or ‘bowstring’, which Samuel Pordage in 1681 in his translation termed ‘neurology’. Thus the name of all the specialities of neuroscience arose, not directly from the brain, but from a description of the cranial and spinal nerve roots. Willis was as great a physician as he was an anatomist and, for many diseases, his is the first clear description. In some there is no previous account, examples being: myasthenia gravis, akathisia (restless legs syndrome) and achalasia of the cardia. In the last mentioned, he explained the disorder of physiology and devised successful treatment with a probang, which he designed. Otologists still diagnose stapes fixation from the symptom of paracusis Willisii. Eastern physicians had previously distinguished diabetes mellitus, but Willis's description (in Pharmaceutica rationalis) was the first in Europe, and his recognition of diabetic neuritis has no precedent.
In other academic centres, anatomists awaited the body of an executed criminal for dissection, possibly twice a year, and this was the earlier practice in Oxford, when William Petty was Professor of Anatomy. The numerous discoveries of Willis arose from other opportunities in his large medical practice. Willis examined his patients carefully, made detailed case notes, and followed his patients throughout their illness. If the outcome was fatal, he usually performed an autopsy, from which examinations arose many of his discoveries. Willis was the world's first neuropathologist (Hughes, 1989). Elsewhere, autopsies were uncommon and, for example, Thomas Sydenham, though an excellent clinician, did not perform autopsies. For many centuries, autopsies have enlarged the understanding of neurological diseases, with great advances in the 19th century, when the histological techniques of the German neuropathologists greatly expanded our knowledge of the nervous system in disease.
Neuropathology in the 20th century
In the 20th century, many other techniques were applied to brain tissue. Chemical analysis and histochemistry revealed the storage disorders of inborn errors of metabolism. Antibodies to receptor sites differentiated the types of neurons and glia and their tumours. The immense magnifications of electron microscopy examined the neuron cell body and its axon and revealed the enveloping myelin sheath. The basis for demyelinating diseases was identified in the parent oligodendrocyte in the central nervous system and the Schwann cell in the peripheral nervous systems. The anatomy of nerve endings and synapses became clear and histochemistry identified their chemical reactions. The electron microscope recognized viruses in diseases, an example being progressive multifocal leucoencephalopathy, a condition discovered by my late colleague, E. P. Richardson junior, of Boston, using the methods of classical neuropathology. In Oxford, hitherto unexplained cases of cerebral demyelination were diagnosed as this condition by electron microscopy of stored fixed tissues (Davies et al., 1973). We also diagnosed stored cases of adrenoleucodystrophy, another disease state identified by Richardson. These are examples of the wealth of discoveries made in neurological diseases in the 20th century, all dependent on the examination of tissue either from biopsy or necropsy. But will such discoveries be made in the United Kingdom in the 21st century? The question invites a comparison of the Anatomy Act of 1832 with the Human Tissue Act 2004.
The Anatomy Act of 1832
During the 18th century, the population of London was expanding and new hospitals were added to St Bartholomew's and St Thomas's: Guy's (1726), St George's (1733), the London (1740) and the Middlesex (1745). In the provinces, most cities and large towns opened hospitals or infirmaries: Addenbrooke's Hospital, Cambridge in 1766 and the Radcliffe Infirmary, Oxford in 1770. Expansion of the existing medical schools was accompanied in London by the founding of private medical schools, in which the teaching of anatomy was prominent. William Cheselden, a leading surgeon, taught anatomy (and physiology), in conflict with the Barber-Surgeons Company, which, with the Royal College of Physicians, claimed a monopoly of anatomical dissection. The Surgeons parted company with the Barbers in 1745 and built their Surgeons Hall, in which they taught anatomy. In 1766 William Hunter and his brother John began at 16 Great Windmill Street an anatomy school with a lecture theatre, museum and dissecting room. Anatomy teaching expanded in the London teaching hospitals, in the provinces and in Scotland. This expansion of anatomical teaching explains the demand for human bodies. Yet the law, from old statutes, allowed only a few bodies of executed criminals to be made available to the medical schools of London, Oxford and Cambridge.
Body snatching was illegal, but the law was not enforced, as the removal of the body was not a crime. The disturbance of the grave was a misdemeanour, and the robbers replaced the coffin and shroud to avoid a charge of theft. Resurrectionists were more at risk from the public than from the authorities, who were influenced by famous surgeons at reputable hospitals, a notable example being Sir Astley Cooper, twice President of the Royal College of Surgeons. The surgeons at the major hospitals gave their services to patients but their philanthropy was not without self-interest. They charged their students for clinical instruction and especially for anatomy tuition. Towards the end of the 18th century the provision of bodies for dissection became a scandal. Body snatchers were aided by undertakers, and the anatomists, aware of these sources, shared the guilt. A poor person dying in a hospital might be dissected in the medical school of that hospital. Bodies were stolen before the interment of an empty coffin weighted with stones to deceive the mourners. The ultimate crime was murder, of poor persons without relatives or friends. Burke and Hare in Edinburgh were not resurrectionists as they murdered their victims for their clients, notably the infamous Dr Knox. Burke was found guilty—on the evidence of Hare—and hanged in Edinburgh in 1829 (Douglas, 1973). The London ‘Burkers’ were Bishop and Williams, who resurrected between 500 and 1000 corpses. Bishop and Williams, who were convicted and hanged for the murder of three of their victims, probably murdered many more.
The response of the government to these scandals was to legalize a supply of bodies from prisons, poor law houses and hospitals. A Select Committee on Anatomy, chaired by Henry Warburton, examined the problem, with much testimony from anatomists and surgeons—Astley Cooper, Benjamin Brodie, John Abernethy and several others—and reported in 1828. On March 12, 1829, Warburton introduced his first Bill, for ‘Preventing the Unlawful Disinterment of Human Bodies, and for Regulating Schools of Anatomy’, but this failed due to opposition in the Lords. Ten days after the execution of Bishop and Williams, Warburton introduced his second Anatomy Bill. Debate now was muted, the main opponent in the Commons being Henry Hunt, MP. William Cobbett vehemently denounced the Bill in his Political Register. Despite the eloquence of ‘Orator Hunt’, the Bill passed the Commons and Lords and became law on August 1, 1832 (The Statutes of the UK and Ireland, 1932).
This Act for ‘Regulating Schools of Anatomy’ required the Home secretary ‘to appoint’ not fewer than ‘Three persons to be Inspectors of Places [to be approved] where Anatomy is carried on’ and to license members of the medical profession ‘to practice Anatomy’. Executors had to respect the desire not to be dissected, expressed in writing or verbally, either by the deceased or a near relative. Undertakers were prohibited from these decisions. No body was to be moved for dissection until 48 h after death and 24 h after permission had been given by an inspector. Bodies had to be moved in a ‘decent coffin’ and after dissection ‘be decently interred in consecrated ground or, in some public burial place ... of the religious Persuasion’ to which the deceased belonged. Prior legislation authorizing the dissection of an executed criminal was repealed, important in separating anatomical dissection from the punishment of a criminal.
The Anatomy Act of 1832 is a milestone of anatomical teaching in Great Britain, legalizing and controlling anatomical dissection. One consequence was that accurate figures were now available. In the following year, 609 bodies were provided for anatomy, 394 from parish workhouses, 135 from hospitals, 24 from prisons and hulks, 5 from asylums and 51 from dwellings. Clearly, the poor dying in workhouses were the chief source of bodies. The Act solved most of the problems of the anatomists, and the theft of bodies ended. Persons admitted to a workhouse or hospital may have feared being dissected if they died in these institutions, though they were protected by the safeguards of the 1832 Act, as described earlier. Whether the wishes of the subjects or their relatives were respected, depended how sensitive to these were the anatomists of the 19th century and subsequent years.
The Human Tissue Act of 2004
This Act arose from public scrutiny of the practice of tissue retention at the Bristol Royal Infirmary and the Royal Liverpool Children's Hospital (Bristol Royal Infirmary Enquiry, 2001; Royal Liverpool Children's Inquiry, 2001). A zealous paediatric pathologist systematically retained the organs of infants and children and it became generally known that this was a common procedure in paediatric morbid anatomy, as was the universal practice in neuropathology of fixing the brain in formalin for detailed examination. An example from Oxford illustrates how a case is examined and how the information gained can benefit a wide circle, including the relatives of the deceased.
A young person was admitted with symptoms and signs of acute encephalitis, although the presentation was atypical and the diagnosis uncertain. Within a few days, the patient died and none of the investigations had identified a cause. The general necropsy examination proved unrevealing, and the cause was presumably in the brain, which was fixed in formalin. Some three weeks later, this was inspected in 1 cm coronal slices but the appearance did not suggest encephalitis or any other recognisable brain disease. However, the selective damage to certain internal nuclei was that seen in carbon monoxide intoxication. Histological sections confirmed this pathology. The relatives were questioned further and the cause was traced to an inadequately ventilated gas bathroom heater, recently converted to a natural gas supply. The coroner was informed and the matter examined in detail at the inquest (with pictures of the histological slides), of great importance to the relatives and to the general public.The Human Tissue Act 2004 in 60 pages and 57 sections attempts to regulate a wide range of activities: necropsies, anatomical dissections, corneal tissue transplants, human organ transplants and procedures related to human fertilization. The Act extends to England, Wales and Northern Ireland but similar provisions have been made for Scotland. The authorization in a single act of these disparate pursuits has produced a complex piece of legislation. Storage of human tissue—defined as tissue containing DNA—receives detailed attention unsurprisingly as this was the main cause of public concern. Anatomical dissections are now regulated only by this Act, which repeals the Anatomy Act of 1984. The status of bodily material in museums and religious relics in churches is also covered by these regulations.
Necropsies ordered by a coroner are distinguished from those made to ascertain the cause of death, for which elaborate permissions and directives have been framed. From September 1, 2006, premises must be licensed (a license costs £6000 annually) and relevant activities controlled by a license holder who is also responsible for any retention of human tissues and their ultimate disposal. Fixed tissue in containers, embedded tissue and histological slides of human tissue are all subject to this regulation and unfortunately the decision may be against retention of any human tissues. Even before the Act became law, there has been a catastrophic decline in the performance of neuropathological necropsies. The diminution is greatest in paediatric pathology and is compounded by early retirements and fewer entrants into this specialty. Paediatric neuropathology, once flourishing in the United Kingdom, is now rarely practised. Coroner's necropsies continue as before and form the largest group of necropsies but this work, outside the National Health Service, determines the cause of an unnatural death. The coroner cannot be expected to order (and fund) necropsies to diagnose natural deaths. It is these necropsies, of direct benefit both to the relatives and the clinicians, which have become infrequent. The absence of these post-mortem examinations curtails teaching of medical students and of clinicians in training. Formerly students and staff regularly saw the actual pathology of neurological diseases but the next generation of doctors in the United Kingdom will not have this experience.
One small but important development is the growth of societies which support patients dying from diseases such as Alzheimer's or multiple sclerosis. These societies encourage relatives to request necropsies to confirm the diagnosis—not otherwise certain—and to permit research on retained tissues. It is the experience of clinicians that relatives not only give these permissions, but also frequently state how welcome this opportunity to assist medical research is. This contradicts intemperate statements in the media and pronouncements by Ministers of the Crown. It also suggests that the overall perception of the public is not that of the vociferous minority who are against necropsies and the retention of human tissues for research.
Green College
University of Oxford
References
Anatomy Acts Object Guide. In Barnes S and French D (Eds.). Scotland & Medicine; 2006, Edinburgh This is a guide to the items on loan and their provenance in Scottish collections. The initiative for this exhibition came from the Scotland & Medicine: Collections & Connections partnership, a consortium of university, local authority, and independent museums together with the National Library of Scotland and the National Galleries of Scotland.
Bristol Royal Infirmary Inquiry. The Report of the Public Inquiry into Children's Heart Surgery at the Bristol Royal Infirmary 1984–1995. Learning from Bristol, London Presented to Parliament by the Secretary of State for Health by Command of Her Majesty; July, 2001.
Castiglioni A. (1941) In Krumbhaar EB (Ed.). A history of medicine. Translated from the Italian(Alfred A. Knopf, New York) pp. 340–5.
Davies JA, Hughes JT, Oppenheimer DR. (1973) Richardson's disease (progressive multifocal leukoencephalopathy): a study of four cases. Q J Med 42:481–501.[Web of Science][Medline]
Dewhurst K. (1980) Thomas Willis's Oxford lectures(Sandford Publications, Oxford).
Douglas H. (1973) Burke and Hare: the true story(R. Hale, London) The Burkers. Hansard, 12 December 1831, n.s. 9, 154–5.
Hughes JT. (1989) Thomas Willis: the first Oxford neuropathologist. In Clifford Rose F (Ed.). Neuroscience across the centuries(Smith-Gordon and Co Ltd, London) pp. 87–96.
Hughes JT. (1991) Thomas Willis. 1621–1675: his life and work(Royal Society of Medicine Services Ltd, London).
Hughes JT. (2003) ‘Alas, poor Yorick!’ The death of Laurence Sterne. J Med Biog 11:156–62.
Human Tissue Act 2004, Chapter 30. (2004) (The Stationery Office, London).
MacDonald H. (2005) Human remains: dissection and its histories(Yale University Press, New Haven) Helen MacDonald is a post-doctoral fellow at the Australian Centre, University of Melbourne.
Anatomy Acts: how we came to know ourselves. (2006) (Birlinn LtdIn Patrizio A and Kemp D (Eds.). , Edinburgh) The exhibition, which opened in Edinburgh, and is moving to other towns in Scotland, is described and illustrated here.
Richardson R. (2001) Death, Dissection and the destitute(Orion Publishing Group, Routledge & Kegan Paul; 1988 Phoenix Press).
Royal Liverpool Children's Inquiry. ( January 30, 2001) Report. (Ordered by the House of Commons to be printed, London).
The Statutes of the United Kingdom and Ireland. (1932) (Eyre & Spottiswoode, London) Vol. XII: pp. 891–4 2 & 3 Gulielmi IV, Cap. 73–5.
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