Nervus Intermedius-How Gross Anatomy Almost Made A Cadaver Of Me

I never considered it cheating. I thought of it as being resourceful, showing initiative. When I began medical school, the world of medical education was in the process of tremendous upheaval. A completely new model was replacing the old system. No longer would students study in turn anatomy, physiology, pathology, pharmacology etc. The new program would be integrative: the cardiovascular system would be studied in all its facets at once—its anatomy, its physiology, and the rest. It was based on some wild new idea that people learned better when information was presented within a conceptual framework with some meaning attached to it, rather than having truckloads of disembodied facts rammed down their throats.

Unfortunately for my classmates and me, my school was having none of it. “It worked for us, it will work for you.” They, meaning the stodgy administration and imperious preclinical faculty, resisted like wounded beasts and finally conceded only after an ultimatum: revamp the curriculum or face a withdrawal of federal funding. It took effect at the matriculation of the class behind us, so we were doomed to slog through the same fetid swamp of information as our soul-crushed forebears.

Knowing this bit of political history, it was interesting to begin classes and actually meet these recalcitrant dinosaurs in the flesh — to look into the eyes of these venerable PhDs who sought to wrest us from the grip of modernity.

Medical school began with the most universally feared course in the curriculum: gross anatomy. It was yearlong and not passing meant retaking the entire year. The professors were, for the most part, grizzled ectomorphs who looked to have cut their teeth on the same corpses as Leonardo Da Vinci. The single youngish professor became an object of pity for me as I contemplated the drudgery of his life in an academic field effectively unchanged for centuries. They were apparently involved in research, but it is hard to imagine what they could possibly have been investigating. It was gross anatomy, what’s new? “Counting the fingers: a multivariate statistical approach.” Or, perhaps, “The feet: further evidence that they are to be found at the end of the legs.”

Each student was issued a bone box. This was a small black trunk with a handle containing an entire human skeleton. I sat for hours in my apartment turning the bones over and over, trying to learn the dozens of named ridges, projections, and bumps each bone contained. It somehow managed not to seem creepy having bones all over my apartment. Or, I should say, not to me.

My first visitor was Sarah, a friend from high school. “How do you sleep with these in your house? I mean, if you get up to pee and you’re half-asleep, and you pass an arm on your dining table? I mean a person, was a person, and…” I held forth to her on becoming inured to such things from sheer exposure – the professional distance – the systematic denial of human spirit in student and subject alike. She wasn’t buying. “I could never, I mean never have these in my space. Never.” I tried to explain that in the scheme of my current life, some dried out bones barely registered a blip on the disturbometer.

Sarah was an artist and both fascinated and repulsed by all things morbid. Her studio was a creepy little place filled with nightmares and dark medieval forests, but her living spaces were always pretty and benign. So it was not that she didn’t like my bones, she just thought it very un-Feng Shui to have them lying all over my apartment. Yet still she was intrigued. “You have got to show me your…body, or whatever.” “Trust me,” I told her. “You’ll never get it out of your head.” “I don’t care,” she insisted. “I need to see it. I need to.”

We arrived at the dissection lab in the late evening. I slipped my I.D. through the card reader and the door plunked open. I watched Sarah as she took it all in from the threshold, standing for a long moment gazing wide-eyed into the vast space. Table after table of sheet-covered cadavers lay before us. Feet poked out from some, a shock of wiry hair from others, a thumb. Thirty yards away a group of four students hovered over their charge barely taking note of our entrance. As the odor of chemicals and death vented over us, Sarah’s hands shot to her face. “Ohmygod,” she managed to utter. “Yes, yes,” I returned with a smile. “Welcome.” I was beginning to enjoy myself.

We slowly walked in, Sarah now content to have just her left hand over her mouth to accent her look of abject horror. We passed to my cadaver, Marty the First. So named from a tattooed “M” on his upper left arm. The suffix was added in a pique of self-deprecation and defeatism among my dissection group to suggest that upon our inevitable failure of the course, there would be for us all, a Marty the Second.

Marty was a medium-built man in his sixties, with several tattoos, who had, judging by even a cursory look at his liver and lungs, lived fast. We dissected out his implanted defibrillator and joked that, like us, it was apparently not up to the task. My group consisted of me; Ed — a big–spectacled, born again Christian, comic book geek who, though raised in Maryland conducted most of his business in an East London accent; a former frat boy, who’s rearward-situated baseball cap seemed to point back towards the kegger he looked to have grudgingly just left; and a woman I always referred to as the Delicate Flower, whose brusqueness and foul mouth could make a longshoreman blush and giggle. We were quite a team.

Sarah had regained her composure somewhat, and I slowly pulled back the sheet to reveal our friend in all his partially dissected glory. His chest and abdominal cavity were wide open, his neck muscles flayed out like gills. Sarah just narrowed her eyes. “What’s that?”

The appearance of a cadaver bears little resemblance to a living person. Being pickled, the flesh is rubbery and colored like dark meat tuna. The organs are dense and friable like pate. They were nothing like the vibrant, undulating, primary-colored innards we would soon be encountering in our surgery rotations.

I noticed Sarah studying his as-yet-undissected genitalia. “Why is it so…swollen?” I explained that there were two schools of thought. One, shared by me and my two male colleagues, had it that there was a post-mortem phenomenon related to fluid shifts, that had rendered Marty’s man-parts engorged beyond all proportion to living reality. The Delicate Flower had a different take: “You guys are pathetic you know that? What, you’re threatened by a cadaver? A cadaver?! Marty was hung like a bear. Live with it.”

After taking Sarah on a tour of the special dissection room, with its heads on the half-shell and mangled limbs of various sorts, we went back to my apartment to make dinner. Sarah had really come around. In that short time, she had managed to develop a thin coating against the horror of dead human flesh. She was hungry. That was a very good sign, though I would wonder years later if our time together contributed to her turn to veganism. As I washed up for dinner, I could hear Sarah in the kitchen. “Could you give the pasta sauce a stir?” I yelled out to her. “Sure,” she said. “Where’s the femur?”

By far the most formidable and imposing of the professors was a tall, weathered Englishwoman named Dr. Phyllis Markham, who sounded uncannily like Julia Child. She would wander the hangar-sized dissecting lab pointing to the vagus nerve in one cadaver, the descending colon in another, her voice undulating through a range of octaves and drifting harmfully through the formaldehyde-thick air. As she approached a table, you could just about hear every orifice, down to the pores of their goose-fleshed skin, closing up like little clams as the students dropped their scalpels and forceps and stood rapt before this august inquisitor, hoping not to be the one asked to expound for example on the course of the facial nerve.

I for one used these moments to spend time in a place I referred to as Julia’s Kitchen. I hoped my vacant stare would render me invisible, and as the anatomy professor gestured toward a puddle of peritoneal fat, what I heard her say was, “look at the beautiful marbling of this roast.”

Dr. Markham was perhaps pointing at clots of thymus, but in her warm, fragrant kitchen, Dr. Julia was pointing to “these lovely chanterelles, just perfect for a wonderful Champignons en Poisson.”

Dr. Markham was unnervingly cheery. It was disturbing to observe someone so happy and content in their gruesome work. It seemed to me that she viewed the world as the Big Anatomy Lab. People were all still-living cadavers, just potential fodder waiting to enlighten and torture the next generation of med students. Even for me it was becoming difficult, when I encountered moribund patients, not to imagine them laid out on our slab, their sinews dull and grey. But I jettisoned these thoughts from my mind like you would an image of your grandparents copulating. Dr. Markham seemed to embrace it all. She was a machine.

Anatomy was so hard, such an unbelievable crush of information. It was also part of an ancient hazing ritual. We were young academic overachievers. We were used to being faced by enormous quantities of material, and given enough time and effort as undergrads it could always be mastered. Here it was impossible. No matter how you studied and went over your cadaver, and imagined every angle of every bone, and every muscle that inserted on it, and nerve that curved around it, and blood vessels branching here, and lymph nodes snuggled there, exam questions would be asked that threw you.

“In an unusual variant of the course of the oculomotor nerve, it passes below rather than above the superior cerebellar artery. Which of the following ten structures would it therefore not pass on its journey to and through the cavernous sinus?” The eyes glazed, the heart raced as one contemplated doing this all over again the next year. Precious time frittered away as visions of weeping parents and homelessness began to dull an already enfeebled mind. And that was the easy part.

Yes, the written exams were children’s puzzles — comparatively stress-free accountings of our scholastic progress. What really filled our hearts with dread, what kept us up late picking through the stinking organs of our cadavers was the practical exam.

You arrive at the anatomy lab as close to the appointed time as possible so as to avoid soaking up too much of the frantic, hyperverbal, fidgety stress energy of the early arrivals. The doors open. The rules are explained. You have one minute at each of the fifty stations after which, a bell will ring and you must move on. Each station has a specimen with a series of small flags pinned to structures of interest. Answer the questions associated with each flag. Touch nothing.

This last bit was clearly included to discourage some students’ nasty little habit of sabotaging exams for others in order to improve their own place on the grading curve.

Our knowing the anatomy was just a jumping off point for the noble sadists who were our faculty. You see a flag and recognize the structure, relief washes over you until you realize you must answer a convoluted question about that structure. Ding! You move on lest the super intense, bespectacled classmate coming in behind you encourages you forward with a forearm shiver.

Next station: muscles of the anterior thigh. But so much has been stripped away it takes most of the time allotted just to get your bearings. Ding! On and on. Joints disjointed, tiny bits of disembodied tissue without a clue to its origins, things confusingly twisted out of position.

It really wasn’t about learning anatomy. It was about performing under the most stressful conditions that could be mustered, about bridling one’s fear, but also just about meanness. Like the family abusers who were themselves abused, the cycle was propagated. And it would be our job to punish the next generation for having the temerity to think they could master the material. Oh, and if you fail any practical exam, you fail the course even though your overall average might be adequate. Sorry. Ding!

And, what’s more, I had a handicap. A learning disability really, though in academic matters it rarely surfaced. I have no sense of direction. As a child, I would become lost in my own elementary school building, trying to retrace my steps and feeling ever more frantic as I kept passing the same damned fire extinguisher and obviously making no progress. Or I’d be running happily with a group of older kids until they turned the block and disappeared leaving me unable to recall how we had reached that corner or how to return.

Over time, I taught myself how to use landmarks and to meticulously log the details of important routes. Even today, if I cross a street and enter a store, when I exit, if I forget that I crossed the street, it will feel very natural for me to walk in the wrong direction.

In time, I realized that the problem was generally a weakness of spatial orientation. In organic chemistry, as an undergrad, I struggled to imagine a complex three-dimensional molecule in my head in order to create its mirror image. With time I could manage it. And I had time. It was college. Sitting comfortably at my desk I would practice working the molecule over and around in my mind. It was akin to learning your neighborhood, where taking on human anatomy was trying to memorize a three-dimensional world atlas, then recreating it amidst the bells and frantic med student murmuring of the anatomy practical.

It was the end of the year. Several of our colleagues had already succumbed and would be taking the entire course again. Their pathetic specters hung low over the dissecting tables as we made preparations for the final exam. It was to include all the new material as well as stations reviewing the vast entirety of what we had learned. I had passed the last practical by a single question. I had no wiggle room.

The exam began as they all had: a mass of stressed out students milling about, pulsing out enough manic power to re-animate the dead. Ding! And we were off. As I made my way around the room, my skin tingled with prickly heat. I breathed evenly and tried to stay focused. I thought I was doing OK, but it was impossible to be sure. The new material covered the most anatomically complex part of the body: the cranial nerves. These come directly off the brainstem and control everything from the neck up. It is an impossible tangle of branching wires winding around and through imponderably tiny spaces, sinuses and structures all packed into a space the size of a grapefruit. Branches to the ears and eyes, the tongue and face. So complicated, so disorienting.

Circling the room, fatigue set in and my confidence flagged. I pictured another year with Julia Child of the dark arts — another year unable to rid my nostrils of the acrid-sweet odor of death and formaldehyde. Just Breathe. I was at the last station. I was breathing, breathing. I looked down, and what I saw made me audibly gasp. Now most people would have been horrified. But it wasn’t the fact that I was standing before a human head sliced in half lengthwise through the face. Maybe once, but not anymore. No. It was that the cut was made at a strange angle, off the sagittal, in order to render the way we had learned the anatomy useless to us.

I stared into this head — which lay like a split coconut — trying to get oriented. The minute was ticking away and its very passage kept me from focusing. I thought, This could be the question. The one I need. This one could save me. I know this goddamn anatomy. I need this. Touch nothing. But that’s not the same as cheating right? I can’t see where I am. I’ll just be gentle. What sinus is that? It looks all wrong. What if I just…. I’m going to be a doctor, right? It’s just the laying on of hands. What am I looking at?

“You have ten more seconds,” said Julia to Jacques. I looked to my left. I looked to my right. Everywhere murmuring, scribbling, pondering. I reached down carefully and slowly brought the two halves together. As they approached, it was like a familiar old road map had opened: internal acoustic meatus, seventh nerve, nervus intermedius! It’s nervus intermedius, of course. I gently let the coconut roll open again. I looked around for witnesses. Nothing. I jotted my answer, then closed my eyes, feeling my heart thump against my breast bone. I released a deep breath. Of course, nervus intermedius, what else? Ding!

My three dissection partners and I went out immediately for beer. It was crucial to beat the rest of our class to the pub so that we would have a couple drinks in us before being exposed to all the malignant post-exam energy. Even after such a well-demarcated climax, they would never stop talking about anatomy, the probable pass mark, specific exam questions, “whadja put for this, oh you did? I thought it was…” They had no off or even pause buttons. It was as if, years ago, they had gotten all worked up about their SATs and just stayed that way. But after a couple pints, we wouldn’t much care.

The Delicate Flower would take pleasure in shutting up our closest neighbors. They would leave in a huff, the vacuum would be filled, and the process would continue. “Alright Dumb and Dumber, I just got through telling your little buddies Itchy and Scratchy over there — you want to talk about the exam, you do it out of my earshot. Now beat it.”

But for now we were alone and we raised our glasses high.

Me: Marty number one, there may be others, but we’ll never forget you.

Frat boy: Marty could party.

Comic book man: Mahty old mate, we feel propa charlie about givin’ ya the ol’ slicey dicey, but lovely to have made your howdydo, and cheers a lot for the glands.

Delicate Flower: Marty, we didn’t know you in life, but in death you became our friend. You were there when we needed you. And what a package.

Male chorus: Fluids. Shifting fluids. Recognized phenomenon.

Delicate flower: My ass. Marty, the ladies of Baltimore salute you.

All: To Marty.

Published on December 11, 2006 at 11:13 pm  Comments (4)  

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4 CommentsLeave a comment

  1. ?????????????????

  2. i love it! cranial nerves piss me off!

  3. beautiful…thanks for the head’s up!

  4. Why is medicine so fucked up? How does this process help create doctors? It seems retarded.


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