AETCOM Module

1.5 The cadaver as our first teacher

Department of Anatomy
GMC, Nandurbar
Dr Harish Wankhede & Dr Dipti Nimje

Assessment:
Summative Assessment: SAQ in Paper I of Human Anatomy
Why cadaver is our first teacher:
- Anatomy is the true essence of basic subjects which gives the medical students
their very first exposure to human body and helps them overcome their
inhibitions. It was Susruta's belief that for one to be a skilful and erudite surgeon,
one must first be an anatomist.
- Cadaver is first teacher in medical education and without its availability
medical education would come to standstill and are therefore the valuable gift to
medical education because cadavers can’t be manufactured like other study
material.
- Cadaveric dissection has been the paradigm of anatomy teaching since
centuries.
- Practice of cadaveric dissection help students to grasp the three dimensional
anatomy and innumerable variations.
- Cadavers are required for studying the human anatomy in all disciplines of
medical science.
- Students in our country have got enormous opportunity of dissecting cadavers
and learning , especially in government medical colleges.
- It is very interesting to know that the medical students of Thailand speak of the
cadavers as ‘Ajarn Yai’ which means ‘Great Teacher’.
Use of cadaver to study Human Anatomy: A historical aspect
Maharishi Susruta (6th Cent BC):
-The Susruta Samhita was written by the famous
physician and surgeon Susruta in the 6th century
BCE.
-He is called as Father of Surgery.
-In Susruta's work, it is evident that considerable
thought was given to anatomical structure and
function, as Susruta was a proponent of human
dissection; his texts include a systematic method
for the dissection of the human cadaver.
-There is also compelling evidence suggesting that the knowledge of human
anatomy was revealed by both inspection of the surface of the human body and
through human dissection, as he believed that students aspiring to be surgeons
should acquire a good knowledge of the structure of the human body.
-Interestingly, in neither the writings of Susruta or of Charaka is there any
indication that animal dissection was practised. Their anatomical knowledge,
therefore, appears to have been gained from human dissection.
-Moreover, their writings show a considerable familiarity with the bones of the
human body.
-The Sarirasthana in Susrut Samhita is made up of 10 chapters regarding the study
of human anatomy. According to the Susruta Samhita, medical students should be
taught the art of making cuts in the body of a puspaphala (a kind of
gourd), alavu (bottle-gourd) or ervaruka (cucumber) prior to dissection of human
cadavers.
Herophilus (335-280 BC):
- Father of Anatomy.
-Was one of the first to dissect the human body and doing
public dissections on human corpses.
-Herophilus studied the ventricles (cavities) of the brain;
traced the sinuses of the dura mater to their junction, known
as the torcular Herophili. Described the floor of 4th ventricle
of brain as calamus scriptorius.
-He described and named the organs duodenum and prostate
gland.
-He was first to measure the pulse, for which he used a water
clock.
-Herophilus wrote at least nine works, including a
commentary on Hippocrates, a book for midwives,
and treatises on anatomy and the causes of sudden death, all
lost in the destruction of the library of Alexandria (AD 272).
Leonardo da Vinci (1452-1519AD):
- One of the greatest painter of all time.
- His most famous art work were Mona Lisa, The Last
Supper, Vitruvian Man.
- His most penetrating anatomical study began in 1506
with his dissection of a 100-year-old man, whose peaceful
death he had just witnessed.
- His earlier dissections and drawings were of animals and
many of his first human images were anatomically
inaccurate and based on studies done by Galen (129-216
AD).
- He dissected around 30 corpses.
- da Vinci must have been an extremely skilled dissector;
his post-mortem material was not chilled, embalmed or
fixed. Fine dissection of the brain and other soft tissues
must have been a huge challenge.
- da Vinci was accused of ‘unseemly conduct’ (and
perhaps witchcraft) and his anatomical studies were
ceased.
Andreas Vesalius (1514-1564 AD):
- Was a 16th-century anatomist, physician, and author of one
of the most influential books on human anatomy, De humani
corporis fabrica (On the Fabric of the Human Body).
- Vesalius is often referred to as the founder of
modern human anatomy.
- He studied the theories of Galen and developed an interest
in anatomy, and he was often found examining excavated
bones in the charnel houses at the Cemetery.
-Previously anatomy had been taught primarily from reading
classical texts, mainly of Galen, followed by an animal
dissection. And no attempt was made to confirm Galen's
claims.
-Vesalius, in contrast, performed dissection as the primary
teaching tool, handling the actual work himself and urging
students to perform dissection themselves. He considered
hands-on direct observation to be the only reliable resource.
Pandit Madhusudan Gupta (1800-1856 AD):
- He was a Ayurvedic practitioner who was also trained
in Western medicine and is credited with having
performed India's first human dissection at Calcutta
Medical College (CMC) in 1836 along with his four
students, almost 3,000 years after Sushruta under the
guidance of Professor Henry Goodeve. He was
fundamental in gathering Indian support for
practical anatomy and in breaking down Hindu taboos
on touching the dead.
Ethics and Cadaver dissection:
-According to principle of autonomy each individual should have
autonomous control over the disposition of his or her body after death.
Means what should or should not be done with his or her body at death,
despite of social need or public interest.
-This principle was overlooked, in fact ignored till 1950s in society. And
unclaimed bodies has become the integral part of anatomical study.
-Use of human cadavers for teaching and training purposes is surrounded by
ethical uncertainties out of which main ethical concern lies in respect to
human life.
-Dissection hall is the ideal place to introduce concepts of humanistic care
and values immediately, laying a foundation for their clinical training.
-Bombay Act No. XI of 1949 passed by Law & Judiciary Department.
Now called as Maharashtra Anatomy Act .
-It is a act to provide for the supply of unclaimed bodies of deceased
persons and, for donation before death by a person of his body or any part
of his body after his death to hospitals and medical and teaching
institutions for therapeutic purpose or for the purpose of medical education
or research including anatomical examination and dissection. Whereas it is
expedient to provide for the supply of unclaimed bodies of deceased
persons.
Social view over use of cadavers in medical teaching and body
donation:
-With increasing number of medical colleges over India the demand of cadavers
for education and research is growing.

-Many religions support the idea of body donation.

-Guidelines are issued under Anatomy Act for accepting bodies for donations in
medical colleges through a willed body program.

-In an survey it was found that only 32% general population is aware of body
donation and only 20% of it are willing to donate their bodies.

-Factors such as social awareness, cultural attitude, religious believes and customs
related to postmortem ritual, fear of donated body will not be treated with respect
and dignity and unacceptability of dissection on body influences the person
decision to become body donor or to donate relatives bodies.

-To overcome this factors efforts are taken by medical college staff and social
workers jointly to change the mindset of society through body donation awareness
campaigns, proper guidance and assistance regarding body donation.
Embalming:
- Embalming is a process of treatment of a dead body so as to protect it from
decay. Embalmment is defined as the ‘treatment (of a dead body) – with
special chemicals – so as to protect from decay’
-History:
-The beginnings of the art and techniques of embalming are associated
principally with ancient Egypt, where, as in parts of Asia and South America,
a dry soil and climate encouraged its development.
-In ancient time embalming methods were well described in 5th century BC by
Greek historian Herodotus. During the middle Ages embalming was done by
specialists who employed the elaborate Egyptian method.
-Leonardo da Vinci, who dissected at least 50 cadavers for study, developed a
method of venous injection for preserving them that anticipated modern
embalming procedures.
-Development of modern embalming: Embalming by arterial injection as a
mortuary practice is considered to have begun in England in the 18th
century. The technique had actually been developed by William Harvey in
experiments leading to his discovery of the circulation of blood, during
which he injected coloured solutions into the arteries of cadavers.
-For cadavers embalmed for dissection by medical professionals, students,
and researchers the first priority is for long-term preservation, not
presentation. Medical embalmers use anatomical wetting fluids that
contain concentrated formaldehyde (37–40%, known as formalin)
or glutaraldehyde.
-The first documented embalming of a human cadaver with formaldehyde
is believed to have occurred in 1899.
Embalming procedure:
Anatomical embalming is performed into a closed circulatory system. The fluid is
usually injected with an embalming machine into an artery under high pressure
and flow, and allowed to saturate the tissues. The venous system is generally
opened and the fluid allowed to drain out initially, although many anatomical
embalmers do not use drainage technique.
Anatomical embalmers may choose to use gravity-feed embalming, where the
container dispensing the embalming fluid is elevated above the body's level, and
fluid is slowly introduced over an extended time, sometimes as long as 24hrs.
No separate cavity treatment of the internal organs is given.
Anatomically embalmed cadavers have a typically uniform grey colouration, due
to the high formaldehyde concentration mixed with the blood. This grey
discoloration is also known as "formaldehyde grey" or "embalmer's grey".
Types of Embalming procedure:
1) Arterial embalming: It involves the injection of embalming chemicals into
the blood vessels, usually via the right common carotid artery. Blood and
interstitial fluids are displaced by this fluid. Excess arterial solution and blood
clots are expelled from the right jugular vein referred to as drainage.
The embalming solution is injected with a centrifugal pump or gravity
method. The embalmer massages the body to break up circulatory clots so as
to ensure the proper distribution of the embalming fluid. This process is
known as a single-point injection.
2) In cases of poor circulation of the arterial solution, additional injection points
like axillary, brachial, or femoral arteries, with the ulnar, radial,
and tibial vessels if necessary are used for injecting fluids. This is called as
multi-point injection method.
In some cases draining from a different site from injection (i.e. injecting
arterial fluid into the right common carotid artery and draining from the
right femoral vein) is referred to as a split embalming.
In many cases, an embalmer use to perform pre-injection were water is
injected from artery and vein is cut open to remove clots and residual blood.
2) Cavity embalming: The embalmer makes a small incision just above
the navel and pushes the trocar into the abdominal cavity. The embalmer then fills
the cavities with chemicals (known as Cavity Chemicals) that contain
formaldehyde, which are also delivered to the chest cavity via the trocar inserted
through the diaphragm. The incision is sutured closed.

3) Hypodermic embalming: It is a supplemental method which refers to the

injection of embalming chemicals into tissue with a hypodermic needle and
syringe, which is generally used as needed on a case-by-case basis to treat areas
where arterial fluid has not been successfully distributed during the main arterial
injection.

4) Surface embalming: An another supplemental method, utilizes embalming

chemicals to preserve and restore areas directly on the skin's surface and other
superficial areas as well as areas of damage such as from accident,
decomposition, cancerous growths, or skin donation.

-Later 3 procedures are used additive to the arterial embalming.

Aims of embalming for anatomical purposes are:
The thorough and complete preservation.
The softness of the tissues, as they are found in the unembalmed subjects.
The colour of the muscles and organs, the securing at least of a brown dark
colour for the muscles.
The distension and the colouring of the arteries.
Composition of Embalming fluid:
-Components of embalming fluids can be grouped as preservatives or
fixatives, germicides (disinfectants), modifying agents [buffers, surfactants
(wetting agents like glycerine), anticoagulants], dyes, vehicles and, finally,
perfuming agents.
-Composition and quantity of embalming fluid used for embalming varies
from region to region depending upon the climatic conditions of that region
and type of dead body (thin or fatty).
Compositions of embalming fluid: Cavity Embalming fluid:
Formaldehyde (37-40% w/v)- 1ltr Formalin- 5-6ltrs
Methyl Alcohol/ Spirit- 1.5 ltrs Methyl Alcohol/ Spirit- 1ltr
Phenol/ Carbolic crystals- 800gm Glycerin- 500ml
Glycerin- 500ml Salt- 200gm
Tap water- 3ltrs Thymol- 50gm
Eucalyptus oil- 10ml Tap water- 3-4ltrs
Eosin- 5ml

Natekar’s embalming fluid:

Glutaraldehyde (2%)- 5ltrs
Methyl Alcohol/ Spirit- 2ltrs
Glycerin- 500ml
Centrimide (Antifungal)- 500ml
Eosin- 50ml
Tap water- 5ltrs
Eucalyptus oil- 25ml
Eosin- 50ml
Care of Cadaver:
- Cadavers are preserved by injecting the embalming fluid though it
requires utmost care once dissection starts because fluid starts oozing out
once incision is taken.
- Cadaver and its dissected part should be kept moist at all times specially
during dissection in dry weather.
- Cadaveric dissected parts should be covered with cotton gauze rolls
dipped in embalming fluid.
- Dissected cadavers should be properly dipped in tank filled with
preservative fluid after dissection is over.
Dissection Hall Etiquettes:
-Working with human tissue requires respect and sensitivity.
-Following guidelines and rules will help the students to understand their
responsibilities while handling the human tissue in dissection hall.

1) Most of our cadavers are obtained through body donation without any
financial compensation. Hence, it is important to give proper respect to
the cadavers. Any disrespect for the cadaver will be disgraceful act as a
human being.
2) Students should maintain professional conduct while in the dissection
hall and outside of the hall, particularly if anyone wants to discuss
anything related to the cadaver.
3) Cadaver and its parts should be handled with due respect.
4) Articulated skeletons and bones are to be given the same respect as
cadavers because bones are also obtained from the cadavers.
5) Use of cell phones and photographic equipments are not permitted in the
dissection hall.
Dissection hall maintenance:
-Dissection hall should have limited access. Only students enrolled in the
course should be allowed in the dissection hall.
-Hall needs to be locked when not in use.
-All tissues removed from the cadavers must be collected and places in the
designated containers or tray.
-No body parts, tissues should be taken out of dissection hall.
-Bucket should be placed under the dissection table to drain the fluid
accumulating on the dissection table.
-Ventilation system in the hall should be designed to remove air on to reduce
exposure to the embalming chemicals fumes and odors.
-All fluid of dissection hall should be drain in bio medical sewage drain and
not in the common sewage drain.
-Proper disposal of cadaveric residue and waste should be done and be treated
as biomedical waste and disposed as per biomedical waste management rules.
Personal safety and self care in dissection hall:
-Cadavers are embalmed with fluid containing formalin, glycerin, phenol and ethanol.
So physical contact with skin and clothing with the cadaver should be avoided.
- Dress should not drag on the floor or dissection table. Cloths with short sleeves
should be used. If long sleeves, should be rolled up.
- Students should wear disposable gloves while working in dissection hall.
- White apron should be worn while working with the cadaver.
- Contact lenses should not be worn in the dissection hall, because lenses can absorb
chemical vapors.
- Shoes should be used to protect from draining fluid and dropped sharp instruments
like scalpel.
-Long hairs to be secured in place with hair pins, bands, etc before starting dissection.
- Not to wear finger rings, bangles, wrist watches, threads, etc that comes in contact
with cadaver.
- All backpacks or other personal items should be left outside the dissection hall or
racks provided in the dissection hall.
- Proper use and handling of the dissection instruments should be carefully
maintained.
- Hands and used instruments should be wash thoroughly before leaving the
dissection hall.
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