Professor Darrel Wijeratne Memorial Lecture

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 38^th 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   19^th .  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    21^st  the Editors of the 38^th 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 38^th 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 38^th 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  19^th  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 30^th 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  30^th 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 38^th 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 13^th 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 80^th birthday celebrations at the Royal Society in 1988.  His 90^th 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 30^th Edition of Gray.  Just five years after I returned to Peradeniya appeared the 35^th 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 38^th 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 38^th 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 38^th 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 38^th Edition of Gray’s Anatomy.