Abstract
Along with anatomical dissection, attendance at hospital autopsies has historically been seen as an essential part of medical education. While the use of the dead body for teaching purposes is losing favour in Australian medical schools, this shift is preceded by a significant decline in the rate of autopsies nationwide (and internationally). The decline of the autopsy has particular implications for pathology training where the capacity to perform an autopsy is a requirement. Rather than join the debates in medical literature about the merits of these shifts, this article goes behind the scenes of a hospital mortuary to study autopsy training and practice from the perspective of those who undertake it. The article first introduces the discipline of pathology—‘the science of medicine’—which is built upon centuries of post-mortem study and establishes the fact of the disappearing autopsy. The article then draws upon data from anthropological fieldwork in a Department of Anatomical Pathology to discuss some of the ways trainees manage the work of cutting up the dead. Concepts such as detachment, immersion and disciplinary practice are covered in during this unveiling of everyday practice in a hospital mortuary.
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Notes
In this statement, I differentiate the hospital autopsy from that of the forensic autopsy. In Australia, unlike the USA and Britain, the term ‘hospital’ or ‘medical’ autopsy (which requires the explicit consent of the patients’ next of kin), excludes those autopsies conducted for coronial purposes (which do not require relatives’ consent). However, even these medico-legal practice are under some threat.
While medical anthropologists are broadly concerned with the study of illness, disease and medical systems, hospitals have been an uncommon area of research. Joan Cassell’s extensive studies of surgeons and intensive care units offer an historic exception (Cassell 1991, 1998, 2005). There have recently been two special anthropological journal collections produced to redress this gap in the literature (Long et al. 2008; van der Geest and Finkler 2004).
Some doctors refer to the tissue samples taken from corpses as biopsies, but officially they are termed ‘specimens’ to differentiate them from samples taken from living patients.
Creutzfeldt-Jakob Disease (CJD) remains one disease whose diagnosis can only be confirmed by autopsy.
In Britain, unlike Australia, the Coronial investigations are more integrated with clinical settings, with hospital pathologists performing “medico-legal necropsies” alongside clinical ones. Tasmanian hospital morgues, one of which I visited on invitation during this research, operate a similar system (James 2006). In contrast big cities on the mainland (including Victoria) have specialist forensic medicine institutes that are generally stand-alone facilities.
The other important element of fieldwork, apart from immersion, is the systematic written account of these observations, informal conversations and learnings (Emerson et al. 1995).
Eeyore is the much-loved character from the ‘Winnie the Pooh’ series written by AA Milne. He is pessimistic, never happy, cynical, grumpy, tortured, often used as “beast of burden” by the other characters.
The findings confirm the potential for emotional and psychological upset: headaches, nausea, dizziness, fear, fainting and disturbed dreams were commonly found in student groups across the globe (Houwink et al. 2004; Abu-Hijelh et al. 1997; Penney 1985; Botega et al. 1997; Nnodim 1996; McLachlan et al. 2004; Sinclair 1997). Some national groups, such as Americans and Canadians, fared worse than others, (McGarvey et al. 2001), and to the point where some researchers outlined symptoms attributable to mental trauma and post-traumatic stress disorder (Finkelstein and Mathers 1990; Hafferty 1991; Nuland 1993). Ethnicity and gender were also suggested as contributing factors in the negative experiences among some groups. For instance, medical students in Oman (Abu-Hijelh et al. 1997) and Nigeria (Nnodim 1996) reported significantly higher levels of mental and physical distress as a result of exposure to the dissecting room than Europeans. Some found women to be more distressed by dissection than men (Snelling et al. 2003), although sociologist Frederic Hafferty concluded that female medical students were simply more honest, expressive and reflective about their emotional responses to the cadaver, and that ‘the posture of detached indifference in [anatomy] lab was not demanded of women to the same degree that it was demanded of men’ (Hafferty 1991: 143).
Personal communication from Richard Williams, Chief Examiner, to Assoc Prof Duncan Macgregor, Department of Pathology, University of Melbourne, on my behalf (10 December 2007).
In the ‘Prep Room’ where specimen preparation took place, green trays of organs sometimes lay awaiting examination, or the ‘blocking’ process required for making slides. When the foetal autopsies commenced, this room also hosted these procedures.
Interestingly, one practitioner of hundreds of autopsies described an experience of nausea and faintness when invited to view surgery. He attributed this unexpected response to his passivity, that he was not actively involved in the process, just viewing it.
The exception is ‘surgery on corpses’ during organ donation procedures (although I recognise the ambivalence inherent in that statement). Transplant surgeons I spoke to were careful to describe the sterility and care taken during such operations. ‘It is done as we would do any operation essentially’, one told me, ‘whereas the autopsies I’ve seen it is generally the technician that does the lopping out of the organs, and it was a bit like lopping’.
22nd November 2007. Jane Prophet is Professor of Interdisciplinary Computing, Goldsmiths College, University of London and was presenting as Artist-in-residence at RMIT University’s School of Creative Media.
I thank Prof Lyndal Jones, Dept of Creative Media at RMIT University, for her insights on the understanding of “the rock” and the way people can think their way into a physical strategy that that becomes habituated through a mental trigger. Though a world-renowned installation artist, Lyndal also has extensive experience as a practitioner of the Feldenkrais method (Feldenkrais 1977 (1972)).
I played a 45 second section from an audio-tape of one autopsy at a conference presentation on death in 2006. The sound was of the skull being drilled open. A number of people approached me afterwards to talk about their reactions. Two nurses in particular commented on their surprise at feeling queasy, despite their familiarity with theatre work (which also involves sawing). They located their discomfort in connecting images of the dead with a sound familiar to them.
The retirement of senior pathologists with vast autopsy expertise represents a loss of specialist skills for complex or unusual cases, or infectious cases (ie., TB, AIDS, CJD).
In Melbourne, all foetal autopsies are funded by the state health department. Adult autopsies are at no cost to families if conducted in, or on behalf of, public hospitals. However, families may be charged if their relative dies at hospital with no functioning autopsy service and the autopsy needs to be conducted elsewhere.
Or, as Latour puts it, ‘restricting the repertoire of actants’ requires constant vigilance (Latour 2005: 227).
A review of autopsy consent practice in over 20% of US teaching hospitals found that 90% of pathologists at these institutions believed the limited autopsies were an unsatisfactory alternative to the complete procedure (Rosenbaum et al. 2000). In Australia, Parker’s national survey of pathologists found that ‘77% preferred the complete autopsy over the limited autopsy for the standard case, although many respondents qualified their answer by suggesting a limited autopsy should be used for known infectious cases’ (Parker 1999: 225.
Here I am specifically referencing Ortner’s discussion of agency as an ‘active’ notion of intentionality that ‘differentiates agency from routine practices’ (p. 136), and Pickering’s point that scientific practice is ‘typically organized around specific plans and goals’ [his emphasis, p. 17] (Ortner 2006; Pickering 1995).
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Acknowledgments
I sincerely thank the staff of “Hillside’s” Department of Anatomical Pathology. These men and women were unaccountably generous in providing access to their workplace, their knowledge, their time, as well as giving their trust. They opened the doors of hospital medicine to me. I also acknowledge the Centre for Health and Society at the University of Melbourne, under whose auspice this research was conducted.
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Horsley, P. Teaching the Anatomy of Death: A Dying Art?. Medicine Studies 2, 1–19 (2010). https://doi.org/10.1007/s12376-010-0042-4
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DOI: https://doi.org/10.1007/s12376-010-0042-4