Trends in Anatomy
- a personal experience
Eugene Wikramanayake MBBS, PhD
Senior Professor of Anatomy
University of Peradeniya
1999
It
is an honour to deliver this lecture, the first of a series to commemorate Darrel
Wijeratne the founder Professor of Anatomy of the University of Ruhuna. The
theme of my lecture too is Anatomy with special reference to its revolutionary
trends which were my fortune to experience first hand when I worked towards a
PhD in Human Genetics at the University of Glasgow from 1965-1968 strangely not
at a Faculty of Medicine but of Science!. My story would be cadaveric without reference to the
serendipitous events, places, institutions and inspiring personalities that swept
me into the mainstream of these radical
trends in Anatomy. It is also imperative
for me to unfold how this fortuitous intellectual endeavor enabled me,
beginning with genetics almost surreptitiously to introduce these trends in the
medical, dental and veterinary science curricula of the University of
Peradeniya over the 30 year period 1968-1998.
Literally,
Anatomy is the dissection or separation of the body into parts. Dissection of cadavers remains the key to
understanding the topography of the body to this day. In the first medical
school of the western world at Padua, 28 year old Vesalius laid the foundation
for the study of Anatomy with the publication of De Fabrica Corporis Humanii
based on the first hand experience of dissecting in 1543. From northern Italy anatomical science spread
to the rest of Europe. In my quest for
global trends in Anatomy however I turn to Henry Gray and St. George’s hospital
London where the first edition of Gray’s anatomy we are familiar with, was born
in 1858. A brief history of Gray the
“man” and his “anatomy” gleaned from the preface and the historical accounts in
the 38th edition published 137 years after the first, follows.
Henry
Gray, the second son of William Gray the Deputy Treasurer to the Prince of
Wales was born in 1827 at Windsor Castle.
After matriculating at 18 years he entered St. George’s hospital as a
“perpetual student”. Gray pursued his
studies with determination and diligence and was known to be a student “who
learnt his Anatomy by the slow and invaluable method of dissections made by
himself”. At 21 years he was awarded the
MRCS and appointed House Surgeon in 1850.
On his research in physiology and avian embryology he was awarded FRS in
1852, a rare distinction at such a young age.
He returned to the dissecting room as demonstrator, then Curator of the
Museum and Lecturer in Anatomy. He
devoted the next six years to producing his Opus Magnum the first edition of
which was published by Parker under the title Anatomy Descriptive and Surgical
in 1858. Gray’s expressed objective was
to furnish the student and practitioner with an accurate view of the human body for practical surgery. A second edition followed
in 1860.
With
Gray’s untimely death from small pox in 1861 Longman acquired the rights and continued
to publish the book under the supervision of a practising surgeon and anatomy
teacher at St. George’s till the end of the 19th . Acclaimed by both Lancet and BMJ, Gray’s text
became established as the manual
for the study of Anatomy both in Europe and America. Envisioning the continued relevance of Gray’s
Anatomy in the medical sciences in the 21st the Editors of the 38th edition of
1995 comment that because Gray’s name is linked worldwide with a text book in Anatomy
many assume that “its contents reflect the intellectual scope of the man”. They
emphasise that his book was written for the needs of students and practitioners
of surgery most of them using it, to sit for strictly prescribed set
examinations. They note that whilst Gray
excelled in the descriptive anatomy of cadavers his scientific and research
interests extended into many facets of the natural sciences. They opine that ‘without question Henry Gray
would have greatly enjoyed to participate in this great adventure the 38th
edition, in which many of the finest minds have been eager to cooperate in
expanding, refining and updating the work in the existing foundation to launch
it towards the next millennium”. The
approaches of the 38th edition they conclude “are justified and
indeed essential if we are ever to gain any real understanding of the human
body’s nature in all its complexity and begin to answer the questions “Who are
we and from whence did we come”.
Gray
was fortunate that the 1850’s also saw the increasing growth and vigour of
scientific medicine and relevance of research and theory to medical
procedures. Louis Pasteur’s experiments on
fermentation and Helmholtz’s on nerve conduction were followed by Gregor
Mendel’s on heredity. Charles Darwin’s thesis on evolution and Rudolph
Virchow’s on cellular pathology were also part of this dynamic decade for
medical science. In addition the Medical Act of 1858 emphasised the
professionalisation of medical practice with regulated access and accredited
training procedures for the study of Anatomy.
Thus for the anatomical sciences Henry Gray was able to meet the
demands of a growing profession and the
surge of scientific knowledge by producing a reliable text in Anatomy by 1858.
As mentioned, until the end of the 19th the editors were practicing surgeons. Histology and Development were introduced by
1887. When medical research and teaching
could provide whole time careers in Anatomy a professional anatomist became
associated with Gray’s Anatomy¸ and its sole editor by 1909. The text was renamed Gray’s Anatomy
Descriptive and Applied and Development was retitled Embryology. Surface Anatomy was introduced in 1913 and Radiological
Anatomy in 1938. With a lapse in
publication due to the Second World War the 30th edition was
published only in 1949.
During
the 1950’s and 60’s with a succession of editors attempting to accommodate factual
increases of knowledge, Gray’s Anatomy became aesthetically unpleasing and
intellectually tedious. For teachers in
medical schools worldwide it became increasingly difficult to extract anatomy
knowledge for medicine from the anatomical sciences, technology and techniques from
Gray. For topographical Anatomy too there was confusion in integrating the
living with the dead and the two dimensional with the three. Anatomists were criticised
for slavish attention to minutiae, endless itemization and rote learning of
cadaveric structures of limited clinical importance. At worst Anatomy was described as a “subject
inhibitory to the intellect” hardly deserving the title of a science. Looking
back at my own study of Anatomy in the early 1950’s however I have no doubt
that the “long hours” spent in the dissecting room was the foundation for the MBBS degree.
Leaving
aside the confusion in Gray and the crisis in the teaching of Anatomy let me
now introduce you to the first serendipitous event, place, institution and
personality who enabled me to personally experience the revolution in the
science of Anatomy that followed. After
my internship, I served as a medical officer of the Outpatients Department of
the General Hospital Colombo. At the end
of 1961 my husband already twenty years in University service had to assume
duties at the newly established Faculty of Medical, Dental and Veterinary Sciences
of the University of Peradeniya. In the
1960’s the Faculty of Arts at Peradeniya was at the height of its intellectual
achievements providing an oasis of learning opportunities both for students and
teachers of the more recently established Faculties as well. With on campus residence provided in a
housing complex of the Professors of Science and Agriculture, communication
across the Sciences was also at hand.
Thus it was this translocation to the salubrious campus of Peradeniya
and its vibrant intellectual atmosphere that lured me into an academic career
in the basic sciences in Medicine.
That
it would be Anatomy, was influenced by the late Professor Lester Jayawardene also
transferred from Anatomy Colombo and housed next door.
With
a PhD in Physical Anthropology from the University of Edinburgh he had plans to expand the horizons of Anatomy
as early as in the 1960’s. So with the
promise of an escape route into Genetics
from its confines, I ventured
into teaching Anatomy in 1962. The main
courses were Topographical Anatomy Surface Anatomy, Radiological Anatomy,
Embryology and Histology as in the 30th
Edition of Gray. The “dissecting room” at Peradeniya was spacious well
ventilated and welcoming. Surface
Anatomy and Radiology could be accommodated.
I too renewed my understanding of Anatomy at depth by prosecting for the
MS Part I in this congenial atmosphere. That World Health Organisation’s
interest in medical education with Anatomy the first subject to come under
scrutiny was also fortuitous. After
training in the use of audio visual aids and improved evaluation methods
introduced by WHO I continued to be actively involved in curriculum development. By early 1965 I had mastered the teaching of
the courses in Anatomy mentioned earlier.
Prof Jayawardene was to remind me later that “it would have been quite
pointless your being here any longer.
Your interest would have palled at the very narrow vista designed for
our medical course”. It was time to
venture overseas for postgraduate studies in Genetics including in Prof.
Jayawardene’s words “it would be nice if you could have the time, energy and
inclination to get evidence for the genetic basis for developmental processes
and a peep into Molecular Biology for a future Human Biology Course”.
Now
I come to the next serendipitous event, institution and personality who brought
me face to face with the revolutionary
trends in Anatomy of this oration thirty years before they were part of the
Anatomical Sciences in the 38th Edition of Gray 1995. Prof Hamish
Munro, later Nutrition Scientist NASA who had supervised my husband’s doctoral
thesis in nutrition advised me too, to
seek furtherance of my academic career at the University of Glasgow. So in mid 1965 I was literally set afloat by
boat to sink or swim and catapulted into
the electrifying presence of one of the leading geneticists of the post war era,
Prof Guido Pontecorvo FRS at the Institute of Genetics, University of Glasgow. In the 1960’s the Institute was an
internationally acclaimed hub of research in Genetics in the UK. It’s enlightening and challenging research milieu was to me personally an
awakening. An awakening that happened
with the first momentous meeting with “Ponte” the personality central to the
theme of this oration “revolutionary trends in Anatomy” He understood my predicament, the long term
goal of introducing Genetics in the Medical, Dental and Veterinary Science
curricula in a flash. Foreseeing the
necessity for me to acquire an indepth insight into the biological sciences his
mentoring began with the recommendation of the text “Introduction to Molecular
Biology” released by the printers to coincide with my arrival in Glasgow! The book edited and prefaced by G.H.Haggis
and co-authored by D.Mitchie, A.R. Muir, P.M.B. Walker from the University of
Edinburgh and K.B.Roberts of the London Hospital Medical College remains my
academic Bible to this day. The preface
quotes the renowned scientist W.T. Astbury saying as early as in 1953,
“Molecular Biology is predominantly three dimensional and structural which does
not mean however that it is merely a refinement of morphology. It must of necessity enquire at the same time
with genesis and function. In the foreword
Professor Whitteridge, FRS says “the authors are concerned to show that there
are no longer sharp divisions between morphological, biochemical, biophysical
and genetic studies of living cells.
These various branches are now complementing one another to give us a more
complete understanding of the diversity and unity of molecular processes at
work in the cell”. To digress it was the same Whitteridge who supervised the doctorate of the Professor
K.N.Seneviratne Founder Chairman of the Post Graduate Institute of
Medicine. It was my fortune to introduce
Genetics in the relevant postgraduate courses during his tenure.
Back
to the story, my introduction to the ongoing research at the Institute was also
unique. Prof Pontecorvo marched me
through the research laboratories beginning with those using the more
sophisticated technology introducing me to both researchers and technical
staff. The final destination was his own
laboratory for the genetics of Aspergillus nidulans, where after the
introductions he proudly presented the simple “whirligig mixer” as the most
useful and least expensive equipment in the Institute. What better way to demonstrate the place of
technology in research to a novice! In
this same laboratory under the guidance of the chief technician I apprenticed
in the methodology of classical genetics. Spearheaded by Prof Pontecorvo
October 1965 saw a combined Biology Course integrating Genetics, Biochemistry
and Virology at the Institute with the text already referred to, the course
enabled me to initiate my understanding of the “human body’s nature in all its
complexity” and begin to answer the questions “who are we and from whence did
we come, envisaged by the Editors of Gray 1995.
Before
leaving for his annual three month working vacation in the States Prof
Pontecorvo advised me to “immerse” myself in the Biology Course whilst scouting
for research prospects in the Human Cytogenetics and Population Genetics
laboratories for my doctoral thesis.
His parting words “your aptitude for research will be tested when I
return”. From that moment “sink or swim”
was my constant refrain. Swim I did with
the tide of the mesmerizing secrets of life at the molecular level unfolded in
the 1950’s. Gray would have understood these at the gross and functional level
from the 1850’s decade of advances of medical science mentioned earlier. Serendipity may have once again played a key
role in my “aptitude testing”. Indira
Gandhi had been elected as Prime Minister of India on the day that “Ponte”
returned to the Institute. He marched me
down a corridor to a phone saying “you Indian women are smarter than the men,
you pretend when you walk behind them”.
He dialled the Registrar and enrolled me for a PhD on the “Formal
Genetics of Man”. Thus began my research
career involving the methodology of both Human Cytogenetics and Population
Genetics. I will fast forward this
intellectually challenging and exciting crucial period at the University of
Glasgow and its environs to continue with
“trends in Anatomy”.
I
was Prof Pontecorvo’s 13th and last PhD student at the University of
Glasgow completing my thesis and returning to Peradeniya on the eve of his
departure to the Imperial Cancer Research Fund in 1968. However his mentoring
and interest in my progress continued by s-mail or during my visits to London
thanks to grants from the Wellcome Trust, Commonwealth and WHO. He reported on my progress to WHO after a consultancy
here in 1982. I attended his 80th
birthday celebrations at the Royal Society in 1988. His 90th was a weekend celebration
at the University of Venice. Provided with accommodation at Padua I didn’t miss
the chance to imbibe the milieu in which Vesalius dissected in the 1540’s nearly
four hundred years before I did.
Back
in the Department of Anatomy at Peradeniya I lost no time in introducing a
course in Genetics in the Medical, Dental and Veterinary curricula open to both
postgraduates and undergraduates of the Biological Sciences as well. However
integrating Genetics in the curricula of the Basic Sciences Departments of the
Faculty remained a challenge. Fortune
smiled on me again in the form of an International UNESCO Workshop on the
“Early Evolution of Life” organized at the recently established Nuclear
Medicine Unit of the Faculty headed by Prof. T.W.Wikramanayake. Interacting with scholars of repute from the
United States, Russia Germany and Japan including our own the late Cyril
Ponnamperuma I fortified myself with a solid foundation in evolutionary
biology. The outcome was the introduction
of a cell biology course in the early 1970’s.
As
mentioned earlier, Anatomy at Peradeniya in the 60’s was on par with the 30th
Edition of Gray. Just five years after I
returned to Peradeniya appeared the 35th Edition Gray’s Anatomy –
New Gray. Anatomy was interpreted in the
broadest sense to include not only conventional morphological methods but also
functional and experimental aspects. The
structure of the human body was described from the ultrastructural to
macroscopic level integrating advances in growth and function. Cytology, histology, embryology and neurology
joined systematic topography making Anatomy a central discipline in the Natural
Sciences. At Peradeniya by then in addition
an integrated cell biology course had taken root.
Immersion
in research in infertility in Sri Lanka (WHO funded) in the mid 70’s saw the
Anatomy curriculum gain a comprehensive Human Reproductive Sciences course with
the ‘morphological’ Male and Female Reproductive Systems in Gray
integrated. Similarly in the early 80’s
inspired by an International Brain Research Organisation (IBRO) Workshop at the
Department of Pharmacology topography of the brain and spinal cord was replaced
with an integrated Neurosciences Course. A study circle in Molecular Biology
for the teachers in the basic sciences was introduced in the late 80’s. The early 90’s saw a paradigm shift in the
curriculum from genetics and cell biology to human biology as envisioned by
Prof Lester Jayawardene in the mid 60’s “a future Human Biology course”. Human Evolution, Anthropology and Behavioural
Sciences with Genetics at molecular level for morphogenesis and histogenesis
was the foundation for Human Biology.
This paradigm shift was also echoed in the approach of the 38th
Edition of Gray 1995 where Anatomy becomes “not merely separation to parts but
an attempt to group the totality of body structure engaging many disciplines, constantly
searching for underlying principles viewing
the living frame as an extraordinary
complex labile entity with temporal dimension, connected by evolutionary
history to all other living organizations, expressing various morphologies as
it develops matures, reproduces, ages and dies in a plethora of integrated functions”.
To
recapitulate in the first edition 1858 Gray’s expressed objective was to
furnish “the student and practitioner with an accurate view of the human body for practical surgery”. The BMJ acclaimed that the “power of the eyes
is beyond all calculation so much quicker in conveying intelligence than mere
abstract reasoning”, also predicting that the book would become the manual of anatomy. The 38th Edition 1995 also echoes
Gray’s objective “the book should address primarily the subject of human
anatomy and should serve the clinical world”.
However
Topography remains the key to understanding Human Anatomy firmly entrenched in
the dissection of cadavers, to display structures with the objective of
obtaining direct experiential knowledge of their size and shape and
topographical relationships. In the early 50’s I spent “long hours” with the recommended
dissection guide displaying structures to the “would be surgeon demonstrators
preparing for the MS PartI, our teacher guides.
Reflecting on this experiential knowledge of topography still vivid in
my memory years later I realised that the three dimensional spatial learning
involved the sense of discriminatory touch more than vision. Although dissection itself is a skill that
can be taught the understanding of topography is a “do it yourself task” for
each individual student.
So,
untrammeled by the crises confronted by teachers of anatomy, using Gray as a
manual in the 50’ and 60’s the study of Topographical Anatomy by “dissection”
was facilitated in parallel with the implementation of the foundation course in Human Biology
since the mid 80’s. The welcoming
atmosphere of the spacious well ventilated “dissecting room” at Peradeniya referred to earlier also
contributed greatly to the study of Topography by the “do it yourself
method”. The “traditional” Anatomy
lecture theatre and tutorial rooms were dispensed with. The established practice of “body donations”
ensured the provision of well preserved cadavers for dissection and preparation
of museum specimens.
The
two weekly dissection schedules for regional topography were replaced by three
hour “dissection” practicals. Museum
specimens, osteology radiology and laminated life size illustrations were on hand
for easy reference. Surface anatomy was
practiced on peers during practicals. Teacher guides facilitated the understanding
of clinical relevance “body side” tutorials were conducted every two weeks. The 800 hours of dissection in the 50’s were
reduced to 300 with the added incentive of a holistic approach to the study of
topography. Continuous assessment
during practicals was part and parcel of
the learning process. The statutory end
of course efficiency bar evaluation consisted of theory, practicals and
orals. Theory was restricted to short
answer open ended questions SAQ. “Walk
around practicals” replaced “spotting” years before OSCE appeared for clinical
evaluation. The orals played a critical
role with emphasis on surface anatomy, osteology and radiology.
In
the late 80’s fortune smiled on the teaching of topgraphical Anatomy at
Peradeniya in the guise of Dr Mark
Amerasinghe retired Consultant Orthopaedic Surgeon a “would be” surgeon
demonstrator I had prosected for, in the 50’s in Colombo. Like the legendary Gray “the perpetual student” of St George’s
who became the Curator of its Museum he became the Curator of the “Dissecting Room”. No other medical school in Sri Lanka has had
such luck. Donned in a white laboratory
coat, his dissection trolley given pride of place at the entrance, the Curator
soon became a magnetic presence and main attraction in the dissecting
room. Whilst Curator Gray dissected to
make illustrations for students to view in
his Manual, Dr Amerasinghe dissected with them, making Topographical Anatomy
“come alive” with dissection no more a chore but a learning process. Displaying structures and demonstrating their
topographical relationships and clinical relevance to students he aroused their
curiosity and inspired them to return to their own dissections to gain the
experiential knowledge expected of them.
He provided the “finishing touch” to my aspiration of “do it yourself” Topography
at Peradeniya. So it came to be that by
the early 90’s the curriculum was in its heyday incorporating the revolutionary
trends in Anatomy envisaged in the 38th edition of Gray 1995 as a
foundation course in Human Biology-Prof Jayawardene’s dream and also a
revolutionary vision for the study of Topographical Anatomy.
Serendipity
again played its part when in the early 90’s WHO called for revolutionary
changes in Sri Lanka with the reorientation of medical education ROME project.
The Peradeniya school made the bold decision to replace its vision from the
study of Medicine with the study of Man in Health and Disease. Informed of this paradigm shift my mentor
Prof Guido Pontecorvo replied “how wonderful even to think about it”. Thus my
personal experiences of this thirty period ends on a happy note as the revolutionary
trends in Anatomy I have detailed were tailormade to be absorbed in reoriented basic sciences curriculum
of the WHO ROME project which became operative in 1995 coinciding with the
publication 38th Edition of Gray’s Anatomy.
