T1 – 003: Two Cadaver

The Anatomy Lesson of Dr. Nicholaes Tulp by Rembrandt van Rijn

…A young boy accompanied me on my journey through a city great and terrible which had formed in our age from smaller cities founded centuries ago – one to the north, one to the south, and one to the east along a great bay. Skyscrapers marked the land yet I with my guide stood on the southern heights where all three cities could be seen.

Intimately close to me upon an adjacent skyscraper was a ledge no broader than an inch trailing along my line of sight as I beheld the eastern city. This ledge was situated outside a particular story from which the ground could scarce be seen, as my guide and I were situated over a cliff on the eastern side of the heights.

Suddenly I noticed a slight movement. The shadow from the adjacent building had placed the ledge in darkness and as my eyes were now adjusted, I noticed young boys were situated between each window upon the ledge, front facing out, clinging onto the walls with flat hands to either side, leaving not a solitary space. This event took place scarce ten feet from my eyes.

I questioned my tour guide as to whether this was a regular practice in this remote and alien part of the world. He replied that every once in a while there is a great and important occasion in the streets below and that as these boys would be too small to see from the ground, they use the height of the skyscraper to behold such momentous events.  From years of practice these boys became so in tune with their own senses of balance that they could fearlessly cling to the walls upon only an inch of ledge.

At that I beheld one of the boys, the nearest to me, fall off and plummet to the streets below. Though the others wanted to help this boy, they knew that if they were to reach out and grasp one of his falling limbs, that they would share his fate.

And so the scene continued at length until the ceremony had come to a conclusion. One-by-one the boys shuffled in through open windows. I, with my sober guide, slowly trod down the smooth northern face of the hill to the shining waters below and continued upon my tour…

***

A formaldehyde molecule consists of a single carbon atom single-bonded to two hydrogen atoms and double-bonded to one oxygen atom. Formaldehyde is both the simplest carbonyl and the simplest aldehyde. In the traditional chemistry curriculum, the study of carbonyls comprises a third to half of organic chemistry. The study of carbonyls generally serves as a bridge between the study of alcohols and the study of biochemistry. 

Although more than nine million tons of formaldehyde are artificially produced per year, approximately 90% of extant formaldehyde is due to natural chemical processes occurring in the upper atmosphere. The average concentration of formaldehyde measured in the human bloodstream is approximately 0.1 millimoles per liter (mmol/L). This concentration tends to increase in urban areas, as formaldehyde is an intermediate of many oxidative processes, such as the combustion of fossil fuels or the decay of plastics. The concentration of formaldehyde, as measured in the human bloodstream, is several orders of magnitude lower than the normal concentrations of carbon dioxide (~25 mmol/L), potassium (~4.5 mmol/L), sodium (~140 mmol/L), and most other small, inorganic metabolites. This concentration of formaldehyde is also several orders of magnitude higher than the standard dose of gadolinium contrast agent for a head CT scan (~0.01 mmol/L), average lead levels in the bloodstreams of US adults (~0.00015 mmol/L), and average warfarin (Coumadin) plasma concentration in patients with therapeutic international normalized ratio (INR) (~0.0015 mmol/L).

For obvious reasons, it is difficult to find good data on acute formaldehyde toxicity. There is an interesting study, stemming from 1905, published in the Journal of Experimental Medicine. Martin H. Fischer injected formalin – a liquid solution of formaldehyde – into guinea pigs. Fischer observed a widespread, systemic inflammatory response, such that he subsequently described formalin as belonging to “that rare group of poisons which are capable of producing death suddenly when swallowed.” It is believed that one ounce (~30 mL) of formalin, if ingested, is enough to cause death in an adult human.

The chemical relationship between formaldehyde and alcohol is worth discussing. Ethanol – the fun alcohol – is comprised of two carbons and one hydroxyl group. As part of normal metabolism, ethanol breaks down into acetaldehyde, a two-carbon aldehyde. It is believed that the accumulation of acetaldehyde is one of the main contributing factors to the disorder known as “hangover”. Acetaldehyde is further metabolized to acetic acid, the main component of vinegar – whether by yeast or by human liver. Methanol, often referred to as wood alcohol, is a one-carbon alcohol and the main component of formalin. It is very toxic. When ingested, methanol breaks down via the same enzymes used in the metabolism of ethanol. Methanol will often linger in the body as formaldehyde before being converted to formic acid, known to cause blindness. Of interesting historical note, the phrase “blind drunk” derives from the Prohibition Era, when bootleg alcohol was often distilled improperly and contaminated with methanol.

While short-term effects of formaldehyde are well-known, as with all substances that are now part of the environment, it is difficult to investigate long-term formaldehyde exposure. This is due to a fundamental inability to conduct a randomized, controlled experiment. It is important to note that, because randomized, controlled experiments cannot be conducted for substances that are part of the environment, well-executed animal-model or well-controlled epidemiological studies showing strong correlation between substances that are now irreversibly part of the environment and negative health outcomes cannot be criticized for not being randomized, controlled experiments. Such criticisms are often levied by corporate interests against environmental or public health scientists. These criticisms are invalid and made in bad faith.

Accordingly, formaldehyde is classified as a “known human carcinogen” by most regulatory agencies. Animal studies and observational studies on human populations with occupational exposure to formaldehyde have shown increased incidence of lung and nasopharingeal cancers, leukemias, and brain cancers. There may also be linkages between formaldehyde exposure and the development of childhood asthma, plus linkages between formaldehyde exposure and spontaneous abortion (miscarriage). Otherwise, no deleterious developmental or teratogenic effects have been demonstrated.

As with many industrially-produced substances that also occur naturally, it is difficult to determine a natural level of formaldehyde, since the compound has been a by-product of industry for far longer than we have been aware of its being a by-product of industry. I’m reminded of Patrick Deneen’s trenchant characterization of the 2010 BP Deepwater Horizon spill:

What’s remarkable about the images of the oil spewing from the severed pipe a mile deep in the Gulf is the widespread belief that this leakage represents an environmental catastrophe, in contrast to the norm, when we control our circumstances by pumping the substance through pipes to containers to refineries to gas stations to automobiles to exhaust pipes to the atmosphere (or, to fertilizer factories to farm machinery to topsoil to erosion to rivers and back to the Gulf). The only real difference at the moment is the concentrated visibility of the disaster, one that makes visible what is usually hidden – that our civilization exists by poisoning our world, by a concerted and organized effort to release toxic substances from confines where they are relatively sequestered for life to flourish, to a condition where we must come to mistrust the food that we eat, the air that we breath, the water that we drink. Rather than dispersed throughout the world – including the very molecular composition of our bodies– the spew allows us to see with unusual clarity the nature of our civilization. Yet we treat it as an exception, a momentary and controllable lapse, the fault of nefarious oil profiteers, rather than the rule, our “way of life”.

Formaldehyde was discovered in 1859 by Aleksandr Butlerov and described further in 1869 by August Wilhelm von Hofmann. Formaldehyde has been observed spectroscopically in interstellar space. On earth, formaldehyde has been observed to form a natural trimer as well as to polymerize infinitely given the right environmental conditions. These are the properties which also make formaldehyde a near-ideal embalming agent.

Formaldehyde has two functional uses in medicine, which are in fact one functional use: it is a biocide, meaning a killer of life, so it is used in small doses as part of vaccination cocktails using otherwise viable toxins in order to confer host immunity; and formaldehyde is a fixative agent. Inside each cell of an organism, DNA is constantly receiving signals from the outside world. Based on these signals, the DNA may transcribe itself to form RNA that will exit the nucleus of the cell and fuse with ribosomes in order to translate proteins. The proteins that are translated are the microscopic actors of life. The functional processes in the body, and indeed the functional processes in all living creatures, are the result of proteins acting.

All of these compounds – DNA, RNA, proteins – contain nitrogen. Formaldehyde acts by creating permanent bonds with nitrogen. If you flood any biological system sufficiently with formaldehyde, you bind up, and effectively freeze, all elements of the system. In a recently deceased human being, by definition, elements are no longer responding to the external environment in a way that will allow the system to continue. If you fix these structures with formaldehyde, you can study their shapes and relationships at the moment of death down to the molecular level and up to the level of gross anatomy. Since bacteria, digestive enzymes, and maggots also rely on nitrogen-containing proteins for action, formaldehyde protects against decomposition…

Some days after my first anatomy lab, I smelled formaldehyde when opening a canning jar. Some light Googling suggested that it could have been a breakdown product from the plastic polymers in the lid. In retrospect, I could have been smelling my own mustache.

Ants have seemingly invaded our apartment here in New Orleans, and my wife has made it her mission to eradicate them.

Bacteria have survived five mass extinctions. At a visceral level – and I suspect I share this sense with the Tibetan Buddhists – I am not scared by nature so much as I am scared by formaldehyde. There is primordial wisdom in bacteria. If the bacteria won’t touch it, should I?

…It is due to the properties of formaldehyde that preserved specimens – corporeal time capsules – exist across the world, in the medical museums of Brussels, Washington, St. Petersburg, Budapest, and Tokyo, in the collections of Mutter in Philadelphia, Fragonard in Paris, and Souchon in this dark city, New Orleans. These specimens remind us how fragile life is, how lucky we are to be here, how far we have come, and how much further we have to go.

***

The hand contains twenty-seven bones, 123 ligaments, more than fifty named arteries, forty-eight named nerves, and thirty-five muscles. The ulnar nerve, which innervates most of the hand, is nicknamed “the musician’s nerve”. The median nerve, which innervates the flexor components of the arm, forearm, and thumb, is nicknamed “the laborer’s nerve”. Seventeen of the muscles controlling the hand are in the hand itself. Eighteen also have components in the forearm. With few exceptions, these muscles perform discrete functions. Almost a quarter of the human motor cortex is devoted to movements of the hand – more for musicians, artists, or surgeons. Fingerprints allegedly exist so we can enjoy even more fine motor control. The words for the various parts of the hand – nail, palm, finger, knuckle, wrist, etc. – are among the oldest in the English language. The American Heritage Dictionary lists thirty-six definitions for the word “hand”, plus another thirty-six phrasal verbs or idiomatic usages.

The thumb alone is controlled by nine muscles; the thumb’s movements include abduction, adduction, circumduction, extension, flexion, and opposition. One muscle of the thumb, the opponens pollicis, effectively differentiates the human from the lesser primates. A nonfunctionality of this particular muscle and its associated group, through median nerve damage and/or severe carpal tunnel syndrome, for instance, is referred to clinically as “ape hand”. Isaac Newton once said, “In the absence of any other proof, the thumb alone would convince me of God’s existence.”

Becoming a hand surgeon is a notoriously long and expensive path. It requires a residency (the period of training after medical school in which specialties are determined) in orthopedics (five years), general surgery (five years), or plastics (five to seven years) – plus a one-year fellowship in hand surgery, thereby totaling at least fourteen years of post-secondary education. It may take far longer for those obtaining a second degree, such as a Masters in Public Health, for those who owe military service, or for those who took time off between college and medical school, now the vast majority of medical students. And despite the relatively high salary that awaits the prospective hand surgeon, as with many of the most dearly-obtained specialties, demand for hand surgeons far outpaces supply.

Another muscle of the hand, the palmaris longus, is absent in fourteen percent of the population. The palmaris longus normally minimally assists several other muscles in the flexion of the hand, although no weakness is reported in individuals with congenital absence of the palmaris longus. Interestingly, the palmaris longus muscle tendon is that which is traditionally used for Tommy John surgery, wherein the ulnar collateral ligament of the medial elbow is damaged and must be repaired or replaced.

Frank Jobe, an orthopedic surgeon who died this past March, first performed Tommy John surgery on Tommy John, a pitcher for the Los Angeles Dodgers, in 1974. Jobe had estimated John’s chances of full recovery at 1%. John went on to make a complete recovery, win 172 games after his surgery, and retire at age forty-six. To date, hundreds of pitchers have undergone Tommy John surgery, and approximately ninety percent of Major League Baseball pitchers who have undergone Tommy John surgery have made full recoveries. Many have even improved performance following the surgery. (Many also, probably due to the mechanics of how they throw the ball, have had to redo Tommy John surgery, even multiple times.) Notable Tommy John surgery recipients include: Rick Ankiel, AJ Burnett, Tom Candiotti, Chris Carpenter, Joba Chamberlain, Scott Erickson, Jose Fernandez, Eric Gagne, Tim Hudson, Jason Isringhausen, Tommy John, Josh Johnson, John Lackey, Jamie Moyer, Kenny Rogers, Ben Sheets, John Smoltz, Adam Wainwright, David Wells, Jake Westbrook, and Kerry Wood. Gagne is the only pitcher who has won the Cy Young award after undergoing Tommy John surgery.

Since Tommy John surgery first took off, baseball dads across the country have been approaching physicians asking them to perform the procedure prophylactically. Since Tommy John surgery first took off, physicians have been telling baseball dads that that’s a stupid idea.

***

As opposed to grave-robbing, body-snatching entails the disinterment of a corpse wherein the corpse itself is the source of value and not the artifacts it is buried with. The heyday of body-snatching was in the nineteenth century, and overwhelmingly the purpose of body-snatching was to sell corpses to medical schools, where they were used for dissection or anatomy lectures.

In Europe and the United States, three historical forces led to the rise of body-snatching in the nineteenth century. One force was the unchecked growth of medical schools and schools of anatomy. The second force was the lack of any kind of system for licensure. (Dissection of actual human cadavers served as a proxy for licensure in terms of conferring legitimacy on a particular school or anatomist.) The third force was the decrease in executed criminals, at that time the only legal source of cadavers for dissection.

Throughout the eighteenth century, it was common in the United Kingdom for the death sentence to be meted out for a great variety of petty crimes, provided that the perpetrator was not a member of the upper classes. This period is referred to today as the age of the bloody code. It lasted from 1688 to 1815. During this time the death penalty was increasingly meted out for offenses today considered minor, such as petty theft – referred to at the time as “grand larceny”. Nevertheless, dissection was a sentence most often reserved for the very worst offenses.

By the nineteenth century, social upheaval led to capital punishment falling out of favor: just as anatomy programs were expanding demand for cadavers, supply was dwindling. The result was widespread body-snatching, usually from fresh graves. Authorities felt the practice was needed, and so they tended to look the other way. At the time in the United Kingdom, body-snatching was classified as a misdemeanor, yet theft was a felony, so body-snatchers often made sure to return clothes and jewelry to recently dug-up coffins before making off with the corpses. It is estimated that, during the heyday of body-snatching, hundreds of bodies were stolen each year in major medical centers such as Edinburgh, London, New York, Philadelphia, Boston, and Baltimore. For the most part these bodies tended to belong disproportionately to members of the lower, disenfranchised classes. Notably, in 1788, in New York City, a medical student at New York Hospital waved an arm out the window at a boy whose mother had recently died. The medical student taunted the boy that the arm belonged to his mother. The boy told his father, who had his wife’s grave exhumed, only to find it empty. Approximately 2000 people participated in the riot that followed, and as many as twenty people were killed.

The forces of economics did not stop at body-snatching. As opposed to a medicine murder, an anatomy murder entails the killing of a human being so as to use the corpse itself for dissection or anatomy teaching. In 1827 and 1828 in Scotland around Edinburgh, William Burke and William Hare carried out sixteen murders in order to sell the bodies to the local medical school. After ten months, the pair were caught, along with their many co-conspirators. Hare turned king’s evidence against Burke, and Burke was sentenced to death and subsequent public dissection.

During the dissection of William Burke, doctor Alexander Monro dipped his quill pen into the blood of Burke and subsequently wrote: “This is written with the blood of Wm. Burke, who was hanged at Edinburgh. This blood was taken from his head.” Medical students rioted when they were all unable to fit into the dissection hall. Burke’s skull was given over to the phrenology department for analysis. Burke’s skeleton is now currently on display at the Edinburgh Medical School, along with a cast of his face made at death and a book bound from his tanned skin. Wallets also made from Burke’s skin were sold following the execution and remain in private collections around the world.

After Burke and Hare, a group of copycat killers, called the London Burkers, came to the fore, in 1831. At this time in the UK, “burking” had entered the lexicon as a term meaning to commit anatomy murder. John Bishop led the London Burkers, a large gang of body-snatchers, who were found to have killed three young boys. After Bishop was apprehended, he claimed to have sold 500 to 1000 bodies over a twelve-year career. Bishop was executed before a crowd of 30,000 and publicly dissected.

In 1832, parliament passed the Anatomy Act. The Anatomy Act replaced the Murder Act of 1752, which had declared that only the corpses of executed murderers could be used for dissection. The Anatomy Act included provisions for anatomist licensure, inspection, rules so as to allow for voluntary cadaver donation for the first time, and arrangements for funerary services following dissection. The Anatomy Act effectively ended the practice of body-snatching in the UK. It was the main law governing the procurement of cadavers for medical schools until 1984.

One of the first individuals to donate his body for dissection following passage of the act was the philosopher Jeremy Bentham, who died in 1832. Bentham’s will included a provision to invite a select group of friends to witness his dissection. Bentham’s will also arranged for his skeleton to be padded with straw and placed inside his own clothes for public display. Originally, Bentham had hoped to have his head mummified using techniques developed by the Maori. This head was to be placed on top of the rest of Bentham’s remains. Nevertheless, mummification failed to produce an aesthetically-pleasing specimen, and a wax replica of Bentham’s head was placed on the figure instead. The whole arrangement is referred to as Bentham’s “auto-icon”, and it is displayed at University College London. For many years, along with the wax replica, Bentham’s real head was included as part of the exhibit, but the head was the target of repeated student pranks, and it has been subsequently locked away. Jeremy Bentham’s auto-icon has developed an extensive mythology.

***

The body is best understood structurally through the study of compartments, which are groups of tissue separated by fascia. For example, the arm (meaning the upper arm) is divided into two compartments: anterior and posterior. The anterior compartment contains flexors such as the biceps, and the posterior compartment contains extensors such as the triceps. For the purposes of simplicity, we’ll say that the forearm’s compartments are analogous to those of the arm. Again, for purposes of simplicity, we’ll say that the hand has analogous anterior (palmar) and posterior (dorsal) compartments; however, it is important to note that thenar (concerning the thumb) and hypothenar (concerning the little finger) compartments exist as well.

The study of compartments is especially applicable to the lower limb (commonly referred to as “the leg”). In fact, a good understanding of compartments and the fascia that separate them is the key to the region, as both blood supply and nervous system innervation, with few exceptions, share a one-to-one relationship with the compartments of the lower limb. From proximal to distal, the lower limb is divided into gluteal, thigh, leg (meaning lower leg), and foot regions. The gluteal region can be treated as its own compartment. The thigh is divided into anterior, posterior, and medial compartments. The leg (meaning lower leg) is divided into anterior, posterior, and lateral compartments. (If you extend your entire lower limb in front of you and look down its axis, you should note your thigh’s medial projection and your leg’s lateral projection.) The dorsum of the foot is typically grouped with the anterior compartment of the leg; the plantar region of the foot is considered its own separate compartment. The remaining compartments of the body include: the cranial cavity, which contains the brain and spinal cord; the head and neck; the thorax; the abdomen; the retroperitoneum; and the pelvis; as well as muscular, soft tissue, and glandular components of the chest and back; and further subdivisions of the various internal compartments.

A compartment syndrome occurs when there is an injury to the structures of one compartment. If the body were a house, each compartment would correspond to a room. Indeed, as a house fire often envelopes one room before moving on to another, an inflammatory process of the body often envelopes one compartment before spreading to another. A common example is shin splints, an inflammatory syndrome of the anterior compartment of the leg caused by overuse of, and damage to, one or more of the muscles of that compartment. Another example is cancer of one or more of the organs of the abdominal viscera: it is considered very bad prognosis if the cancer has spread beyond the abdomen to the thoracic compartment.

Thinking of the body as a group of compartments is helpful for learning anatomy in organized, systematic, and clinically-relevant fashion. Although the formation of a true human mental image comprises hundreds if not thousands of hours of rote study, a solid conceptual foundation of the spatial relationships among the twenty-plus compartments listed in this section can be a very high-yield jumping-off point.

Anatomy is like a three-dimensional geography. The student of anatomy, the future physician, is a perpetual adventurer. The compartments of the body are its continents or great empires, and the individual components of each compartment are the body’s many nations, its cities, its industries and treasures, as well as the directed energies of its individual citizens, working cooperatively to ensure the well-being of the organism.