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How can anatomy be taught as a science and fulfill its purpose as a foundation for medicine.

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3. HOW CAN ANATOMY BE TAUGHT AS A SCIENCE AND
FULFILL ITS PURPOSE AS A FOUNDATION
FOR MEDICINE?
C. M. JACKSON
Institute of Anatomy, University of Minnesota, Minneapolis
It is now generally agreed that in medical schools the fundamental branches should be taught primarily as sciences, but a t
the same time with a view t o their purpose as a foundation for
medicine. Thus anatomy on the one hand must furnish a comprehensive and rational explanation of the form and structure
of the human body, and on the other hand it must provide a
‘working knowledge’ as a basis for subsequent study in physiology,
pathology, and clinical medicine. This ideal with its twofold
purpose is clear. The question is, can it be realized? And, if so,
how is it to be done?
The primary purpose-to teach human anatomy as a scieisceis, a t least in theory, not an especially difficult problem. In
general, the object is to study the human mechanism in the light
of its individual and racial history; to explain the human body
as a biological organism. Given a competent teacher, students
familiar with the principles of animal morphology, and the
facilities of a modern anatomical laboratory, this task could
readily be accomplished. It would require merely a carefully
planned lecture and laboratory course, including a brief dissection of the human body, with correlated work in histology and
embryology.
But this knowledge of the general principles of human morphology, while indispensable, is insufficient for the needs of the
medical student. His training must include more. He needs
in addition many specific details of human structure which are
necessary t o solve the problems of physiology, pathology, and
351
3 52
C. M. JACKSON
clinical medicine. To teach anatomy as a science and at the same
time to meet the requirement for specific knowledge in the brief
time available is the difficult task which confronts us as teachers
of anatomy.
From the clinical point of view, it is desirable that the medical
student should know all about human anatomy, since the exact
details needed cannot be foreseen. Yet this is clearly impossible.
The student might easily spend years in the study of gross anatomy alone, without exhausting the subject.
It is evident th,at there must be a selection of the subject matter
to be taught. The best that can be done is in teaching anatomy
as a science to use as illustrative material so far as possible thosc
concrete details most likely t o be of use later and to present them
in such a way as to give the student a collateral training which
will be of maximum value.
To make wisely this selection of subject matter with a view to
its practical application later requires of the anatomist a knowledge of the subsequent work in medicine. While it is not necessary for him to be a graduate in medicine, he should at least have
a sufficient comprehension of physiology, pathology; and clinical
medicine to judge as to what will probably constitute the most
useful preparation for these subjects.
Even with the best possible selection of subject material, much
anatomy which the student may need must necessarily be omitted.
The situation is materially improved, however, if the elective
principle is adopted in the medical curriculum. According to this
principle, it is frankly recognized that no student can be expected
to learn all about every useful subject in the curriculum. He can
hope at best merely to get a fair grasp of the fundamental principles in each subject, with such details and training in handling
them as will serve his purpose in the more frequently met and
important phases of medical science and practice.
By cutting down the various required courses to the bare
essentials, the medical curriculum, now overcrowded in most
schools, can be somewhat reduced so as to give room for electives.
This will permit the individual student to supplement his required
courses by further eleclive work in the lines of his greatest needs,
353
TEACHING O F ANATOMY
and thus give him a training better than is possible with an inflexible curriculum. While the time which can thus be devoted
to electives is necessarily limited, the system is a decided improvement. Although but few medical schools have as yet adopted this
principle, many more will doubtless do so when its advantages
are better understood.
Our experience with the elective system in the Medical School
of the University of Minnesota may be of interest in this connection. In 1914 we reduced our overcrowded and inflexible medical
curriculum from a total of about 4,800 hours to 3,624 hours of
required work. Throughout the sophomore, junior, and senior
years, on two half-days a week no required work is now scheduled,
this time being left open for elective courses offered in the various
departments. From these elective courses, each student must
choose the equivalent of six hours a week, or a total of 576 hours
in the three years. Thus about 14 per cent of the curriculum is
made up of electives, which may be chosen in any line for which
the student is prepared.
In general, the system has worked out well, and is very satisfactory to both students and faculty. As in other departments,
the amount of required work in anatomy had to be reduced, in
order to give room for electives in the curriculum. By abbreviating some of the courses, and making topographic anatomy elective, the required work in the department of anatomy (including
gross anatomy, histology, and embryology) was reduced from 832
hours to 688 hours. This required work is now distributed as
follows:
1
SUBJECT
HOUR8
I
YEAR
~~
Gross anatomy.. ...............................
Histology ......................................
Embryology, ...................................
Neurology. ....................................
~~
~~
Total .......................................
THE ANATOMICAL RECORD, YOLUME
14, NUMBER 6
First
First
First
Second
336
160
96
96
I
688
I
354
C. M. JACKSON
Various electives are offered in the department of anatomy,
with enrollment, during the past year as follows:
Special dissections. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
32
Topographic m a t o m y . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
14
-4pplied anatomy.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Advanced anatomy
.........................................
18
Anatomical drawings. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Anatomical technique. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Advanced histology. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Implantation and p h e n t a t i o n . . . . . . . . . . . . . . . . . . . . . . . . . . .
Fetal anat,oniy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
13
Special ‘embryology. . . . . . . . . . . . .
........................
8
Experimental neurology.. . . . . . . . . . . . . . . . . . . . . . :. . . . . . . . . . . . . . . . . . .
5
Research i n anatoniy.. . . . :. . . . . .
........................
I0
hat,ornical seminar. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
8
__
Total enrollment.. . . . . . . . . . . . . . . . . . . . . .
These electives vary in time, the average occupying about 80
hours. Thus, the total of the electives taken in anatomy amounts
to an average of nearly 170 hours for each student in a class of 7 5 .
This mould bring the total average per student up to about 858
hours (required and elective), or slightly more than that formerly
reyuired of every student. Even though the total amount of time
devoted to anatomy were the same, the efficiency of the instruction would be increased, because the work is distributed more in
accordance with the varying needs and capabilities of the individual student.
The elective systeizi requires more work by the staff, for it is
evident that to teach several shorter, more specialized courses t o
students in small groups will require more work than to teach an
equivalent amount of routine class work to students in larger
groups. But the results justify the increased work by the staff,
and the elective courses are profitable to the teachers themselves
as well as to the students.
The students who choose their elective work in anatomy do so
for various reasons. A few (would there were more!) take advanced anatomy because they become interested in the subject
for its own sake or as a possible career. The maiority elect it because they realize the advantage of a more extensive training in
TEACHING O F ANATOMY
355
anatomy as a foundation for clinical work. Some have in mind a
better preparation for definite clinical fields in which they hope
later to specialize. Whatever-their purpose, the elective system
permits them to obtain a training in anatomy far better than
wauld be possible under the inflexible required system.
Another phase of increasing importance in medical education
which concerns anatomy is the graduate work. The modern
university must meet the growing demand for trained specialists
in the various fields. In this connection, matomy is concerned,
1) in the training of anatomists themselves, as recruits to the profession and, 2) in contributing t o the training of specialists in
other fields. As a major line of graduate work, anatomy should
be open to candidates for the Master’s or Doctor’s (Ph.D.)
degree in the graduate school on the same basis as any other
scientific subject. Teaching fellowships should be provided which
will help to defray the student’s expenses, while the experience
in teaching will probably be of great value to him in his future
career. The training of recruits for the profession of anatomical
teaching and research is an important phase of our work which
deserves careful consideration.
The most recent phase of graduate medical education is in the
clinical branches. Even under the elective system it is a recognized impossibility to provide adequate training for specialists
in the various departments of medicine and surgery in the undergraduate curriculum. For the adequate training of such specialists, at least three years of graduate work are now generally considered essential, and the universities are beginning to make
definite provision for the establishment of such courses. In this
new field of graduate medical education, anatomy is also directly
concerned, as is evident when the requirements for adequate
training in clinical subjects are considered.
I n graduate clinical work, as in graduate work generally, no
definite and fixed curriculum can be formulated, the work being
advanced in character and adapted to the individual student.
Certain general principles are self-evident, however, and should
be kept clearly in mind in planning the work in each case. It
must be remembered that in anatomy, as in the other funda-
356
C. M. JACKSON
mental sciences, the training of the average medical student (as
we have seen) has necessarily been limited to that which may suffice for purposes of general practice. If he desires to specialize in
any clinical branch, he must strengthen his foundation by further
work in the fundamentals, otherwise the clinical superstructure
will be unsatisfactory. Just as anatomy, physiology, and pathology form the foundation upon which the undergraduate clinical
training is supported, so must more extensive work in these fundamentals form the basis for any efficient system of graduate training in specialized clinical lines.
We have had considerable experience at Minnesota during the
past few years in the development of graduate work in the clinical
subjects, and it may be of interest to know how it works out with
reference to anatomy. As might be expected, those specializing
in the various phases of internal medicine require, as a rule,
comparatively little additional work in anatomy. In surgery
and allied subjects, however, the graduate students find it profitable to spend a considerable amount of time on advanced work
in anatomy. They frequently make anatomy their minor department in working for advanced clinical degrees.
In ophthalmology and oto-laryngology, for example, the graduate students usually take advanced work in anatomy for two halfdays a week during the first year. I n the first semester this work
is in gross anatomy, consisting of 1) a review of the skull, with
intensive study of special preparations; 2) topographic anatomy
of the head and neck, studied especially by sections in the three
planes, and, 3) special dissections for the regional anatomy of the
eye, ear, nose, and throat. This is followed in the second semester
by a similar study of the special histology and embryology of the
eye, ear, nose, and throat, including gross fetal dissections and histological preparations of these regions in the human embryo and
adult. Those making anatomy a minor are required to take additional work in some appropriate phase of the subject. For
example, the wax-cast model of the adult nasal cavity and paranasal sinuses (which is demonstrated at this meeting) was constructed by Dr. Con-nor as a part of his work for a minor in
anatomy.
TEACHING OF ANATOMY
357
Thus it is evident that anatomy must play a rdle of increasing
importance in the development of graduate work, not only in the
training of professional anatomists, but also in the training of
clinical specialists in the various branches. In these new fields of
anatomical work, as well as in the older and more familiar lines,
the question of methods of teaching is one of perennial interest.
Lack of time prohibits me from considering pedagogical methods,
aside from a few general principles which may be briefly
mentioned .
In the first place, uniformity of methods in teaching anatomy
is unnecessary and even undesirable. The methods .would naturally vary according to the preparation and ability of the students,
the facilities available, and the individuality of the teacher. To
be efficient, however, they should regard the past, the present,
and the future. As to the past, the instruction in anatomy should
of course be closely related t o the previous work in zoology. As
to the present, every effort should be made to correlate the work
in gross anatomy with that in histology and embryology. And
the future applications should be kept constantly in mind, as has
already been emphasized.
The physiological view-point is one which is often very usefuI
in teaching anatomy, even though we may not go so far as to
admit that “anatomy without physiology is like an old maid
without a dowry.” In reviewing the locomotor apparatus, for
example, I have found it a stimulating exercise for the students
t o reason out what symptoms would be expected if a given nerve
trunk were cut and to give a complete explanation of the various
structures involved. In the case of a mixed nerve, such as the
femoral, this would involve both sensory and motor symptoms.
The explanation of the sensory symptoms would include the distribution of the various sensory branches to corresponding areas
of partial or complete anesthesia in the integument, joints, and
muscles. The explanation of the motor symptoms would include,
in the first place, the posture of the part, due to the unopposed
action of the unparalyzed muscles. In the second place, it would
include the movements which would be weakened or lost, due t o
partial or complete paralysis of the muscle groups innervated by
358
C . M. JACJCSON
the various branches of the nerve. Such an explanation thus involves a review of the anatomy of the nerves, muscles, bones, and
joints in considerable detail. But it does more in that it helps to
organize that, knowledge into a workable form of obvious value
later not only for physiology, but also for clinical medicine. In
general, in our methods of teaching we should always bear in mind
that, as ex-President Eliot has said, professional training is primarily not for information, but for power.
T o summarize briefly: human anatomy can be taught as a
science, and must be if it is to be efficient. By a judicious choice
of methods.and selection of subject matter, it can also fulfill its
purpose as a foundation for medicine. The difficulties due to the
limitation of time may be largely overcome by the adoption in
the medical curriculum of the elective principle, permitting students to take supplementary work in anatomy corresponding to
their individual needs. Graduate courses in anatomy should
also be provided for those desiring to specialize further, either in
anatomy or in other medical subjects. The methods of instruction in anatomy may vary, but they should always have due regard for the preparation of the student, should correlate closely
the various phases of the work, and should develop a ‘working
knowledge’ which will serve as a basis for future application.
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