Andreas Winkelmann

Anatomical dissection as a teaching method in medical school: a review of the evidence.

Context  Discussions about dissection as a teaching method in gross anatomy are characterised by a lack of objective evidence.

Hermann Stieve's clinical‐anatomical research on executed women during the “Third Reich”

Hermann Stieve (1886–1952) was Director of the Berlin Institute of Anatomy from 1935 to 1952. His research on the female reproductive system is controversial, as some of his scientific insights derived from histological investigations on the genital organs of executed women. These investigations were made possible by the sharp increase in executions during the “Third Reich.” Stieves research was methodologically accurate and contributed significantly to contemporary scientific debates. Nevertheless, his use of the organs of execution victims, some of them resistance fighters, benefited from the Nazi justice system. He thus indirectly supported this system of injustice. The allegation, however, that Stieve “ordered” the death of prison inmates according to their menstrual cycle, appears to be incorrect. An appraisal of Stieves research should avoid traditional black‐and‐white classifications of research during Nazi times. In our opinion, Stieve was neither a murderer nor a fervent Nazi. Nevertheless, his research results were flawed by their ethical and political context. Stieve will remain a somber footnote in the biographies of many execution victims. Clin. Anat. 22:163–171, 2009.

Consent and consensus—ethical perspectives on obtaining bodies for anatomical dissection

Biomedical research and education benefit from the use of human cadavers. These are usually acquired from donors who have willed their body to science during their lifetime. This concept of donation through “informed consent” respects the personal autonomy of the donor and the dignity of the dead body (extended from the dignity of the living person). The concept of informed consent is taken from research on living human subjects regulated in the Helsinki Declaration. This transfer to the domain of anatomical donation, however, has several problems. For example, the dead cannot speak for themselves and the ethical status of the human cadaver remains ambiguous. It is therefore suggested that an element of consensus is added to the concept of consent, a consensus between donors, relatives, anatomists, and the wider community. A consensus can give difficult decisions surrounding body donation and dissection a broader basis and can help bridge the gap between donors and families on the one side and anatomists, researchers and students on the other side. This approach can help to establish relationships of trust with local communities, on which body donation programs depend. Clin. Anat. 29:70–77, 2016.

The Anatomische Gesellschaft and National Socialism – A preliminary analysis based on the society proceedings

The Anatomische Gesellschaft (AG) is an international society for the anatomical sciences and at the same time the main organising body for German anatomists. This study analyses how the AG went through the years of National Socialism. As the society does not possess archival material from that time, the analysis is mainly based on the society proceedings (Verhandlungen der Anatomischen Gesellschaft) published annually after each meeting from 1934 to 1939 and again in 1950. During the period of National Socialism, the AG kept its international status against demands to make it a purely German society. It did not introduce anti-Jewish regulations or the Führer principle into its bylaws. The membership directories reveal that it was at least possible for members whose career was disrupted by Nazi policies to remain on the membership lists throughout the Nazi period. However, in contrast to later assumptions that no persecuted member of the AG was ever struck from its register, 17 of 57 persecuted members left the society between 1933 and 1939. The membership of six of these members was cancelled, officially for unpaid fees. However, other members with much longer arrears were not cancelled. To date, no additional historical information is available to assess the circumstances of these cancellations. In general, it remains remarkable that, in contrast to many other societies, the AG did not follow the path of preemptive obedience towards the new rulers. More archival sources need to be uncovered to elucidate the external influences and internal negotiations behind the published documents.

Acknowledging Tissue Donation: Human Cadaveric Specimens in Musculoskeletal Research

Human cadaveric specimens are an important resource for research, particularly in biomechanical studies, but their use also raises ethical questions and cannot simply be taken for granted. It was asked how much information authors publishing musculoskeletal research actually give about such specimens and about how they were acquired. The aim was to formulate recommendations on how this reporting might be improved. Relevant articles published between 2009 and 2012 in four North American or European journals were scanned for information regarding the characteristics of the human specimens used, their institutional source and the ethical or legal context of their acquisition. While the majority of articles report biological characteristics of specimens (sex, age at death, preservation method), only 40% of articles refer to body donation, only 23% report the institution that provided specimens, and only 17% refer to some kind of formalized approval of their research. There were regional and journal‐to‐journal differences. No standard for reporting studies involving human specimens could be detected. It is suggested that such a standard be developed by researchers and editors. Information on the source of specimens and on the ethical or legal basis should be regularly reported to acknowledge this unique research resource and to preserve the good relationship between researchers and the communities, that provide the required specimens by body donation and upon which researchers depend. Clin. Anat. 29:65–69, 2016.

Should we teach Abernethy and Zuckerkandl

In this study, the author analyzed the relevance of anatomical eponyms for medical education by researching 453 anatomical eponyms and their corresponding English or Latin terms in the Medline database. The number of hits in the database ranged from 0 to 34,490 per eponym (median 11). Almost a quarter (110) of the eponyms did not appear at all. Only 11% of those articles that use anatomical eponyms in their title or abstract added a descriptive English or Latin term. In conclusion, familiarity with many of these eponyms is superfluous for medical students, as they are not in common use by the medical community. However, a number of eponyms must be actively retained by students to understand clinicians and efficiently research medical literature. Clin. Anat. 25:241–245, 2012.

Schlemm, the body snatcher?

Friedrich Schlemm (1795-1858) is well known for his original description of the scleral venous sinus, known since as Schlemms canal. He grew up in a village in the Duchy of Braunschweig (Brunswick). As his family could not afford higher education, he was apprenticed to a barber-surgeon in Braunschweig. This gave him the opportunity to study anatomy and surgery at the local Anatomico-Surgical Institute. Recently discovered archival sources demonstrate that, in June of 1816, Schlemm and a fellow student disinterred the body of a deceased woman late at night in a Braunschweig churchyard to bring the body to this Institute and study the effects of rickets on the womans bones. They were caught and sentenced to 4 weeks of prison. Subsequently, Schlemm left Braunschweig and found work as a low-rank army surgeon in Berlin. Professor Rudolphi, the director of the Berlin Institute of Anatomy, took note of Schlemms manual dexterity in anatomical dissection and supported his impressive career. Schlemm eventually became full professor of anatomy in 1833 and spent his remaining 25 years in Berlin with a focus on teaching students and training surgeons. As historical background information is largely lacking in this regard, it is impossible to decide whether Schlemms episode of grave robbing was a solitary instance or a more common method of acquiring bodies for anatomical instruction in early 19th century Germany.

Guidelines for Reporting Original Anatomical Studies – Quality and Ethics

In their recent article, Tomaszewski et al. suggest “Guidelines for reporting original anatomical studies” to facilitatemeta-analyses and systematic reviews (Tomaszewski et al., 2017). We applaud this effort to improve reporting of anatomical studies and to advance evidence-based anatomy. However, we suggest a revision of the section on ethics that concerns cadaveric specimens. The suggested final list of 29 items of an “Anatomical Quality Assurance Checklist,” produced via a Delphi Procedure involving 12 anonymous anatomical experts, does include an “Ethics” section under “Methodology” (item 16). This section asks authors of anatomical studies to “Provide the details of compliance with ethical guidelines” including details of review board approval. The checklist explicitly “endorses the Helsinki Declaration and its later amendments” and finally requests that “details of written, informed consent should be clearly stated.” This section on ethics covers research on living research subjects, but as the Helsinki Declaration does not concern research on bodies of deceased persons, it remains unclear whether Tomaszewski et al. have considered the use of the latter in this ethics section, even if they explicitly include “cadaveric” as one of the possible study types under item 5 (study design and fundamentals). It also remains unclear whether item 8 (subjects) is meant to cover body donors or other tissue sources as well as living research subjects. In contrast to theHelsinki Declaration, the “Recommendations of good practice for the donation and study of human bodies and tissues for anatomical examination” issued by the IFAA (International Federation of Associations of Anatomists, 2012; Jones, 2016) do explicitly cover research on donated bodies and should be referred to as the only formal ethical standard available in this field and endorsed by the accepted organization of the international community of anatomists. Reference to these recommendations would cover questions of willed body donation based on informed consent of the deceased during their lifetime, following their free decision and documented inwriting. It has been shown that reporting of cadaveric studies indeed has its shortcomings, with the majority of papers lacking information about their sources of cadaveric material and their compliance with ethical guidelines (G€ urses et al., 2016; Winkelmann et al., 2016). It was therefore suggested that the following standard information be reported in all cadaveric studies: “What are the biological characteristics of the specimens (sex, age at death, preservation method)?/Was there written consent of donors during their lifetime?/Which institution provided the specimens?/Which was the legal/ethical basis for the availability of specimens (e.g., local laws or guidelines, approval by review boards)?” (Winkelmann et al., 2016). We encourage incorporation of this standard information, together with a reference to the IFAA Recommendations, into the AQUA quality assurance checklist. We acknowledge that there are countries which have not yet been able to establish body donation programs, mainly for cultural or religious reasons (Gangata et al., 2010; Riederer, 2016). Anatomical research from such countries should therefore not be generally rejected, if it is legal by local standards. However, as the above suggested standard information implies, transparency should be achieved regarding these local standards and the exact source of bodies or tissues, be they from unclaimed bodies, bodies in pathology or forensic departments, tissues surgically removed from living patients, or other sources. However, we strongly recommend that research on executed prisoners be prohibited. Anatomists should not benefit from such a controversial legal practice (Hildebrandt, 2008), even if it may still be legal to do so in some places. In addition, the suggestion to acknowledge donors in the acknowledgment section of an article (Benninger, 2013) is also relevant. Such an acknowledgment does not necessarily improve the information standard needed for evidence-based anatomy, but it should be included in the suggested checklist, as it improves the ethical standard of anatomical papers. Finally, we suggest that an ethics domain be added to the “Anatomical Quality Assessment Tool” published by the same authors in the same issue of Clinical Anatomy (Henry et al., 2017), which does not cover ethical aspects at all. While it might be argued that ethical considerations do not contribute to the quality of anatomical research in the sense of enabling meta-analyses and pooling of data, we would strongly caution against the omission of any ethical considerations in the assessment of the “quality” of an anatomical study. It is fully

Response to "The neglected cranial nerve: nervus terminalis (cranial nerve N)".

I would like to thank Joel Vilensky for his comprehensive account of the history of the “neglected” nervus terminalis (Vilensky, 2014). I would like to add two findings from the European literature, which may help to complete the picture. The first one regarding the earliest reference to the nerve as “cranial nerve zero,” which Vilensky found in the introduction to a conference volume of 1987 (Demski and SchwanzelFukuda, 1987). I was actually able to find an earlier reference to the designation “cranial nerve zero,” if only in its German version, “0. Hirnnerv” or “nullter Hirnnerv.” This designation can be found in a 1974 volume of a handbook of zoology, in which two authors from Berlin detail the comparative anatomy of the brain (Schober and Brauer, 1974). Just like Demski and Schwanzel-Fukuda in 1987, Schober and Brauer do not provide any citation for their use of this term. However, one of the authors, Prof. Kurt Brauer, now of Leipzig, Germany, was still available for an enquiry over the phone. He can still remember the use of this special term. According to his recollections, it had already been in quite common usage at the time. This is supported by the fact that the French version “nerf z ero” can be found in another publication of the early 1970s, which discusses the nerve in the context of premandibular arches of vertebrates (Lessertisseur and Robineau, 1970). Again, these authors do not give any earlier source for “nerf z ero.” It will most likely prove difficult to identify a single person or publication that introduced the term. Second, and more surprisingly, German textbooks of the 1940s and 1950s list the nervus terminalis as cranial nerve number II, preceded by “Fila olfactoria” as number I, and thus replacing the optic nerve (see, e.g., Clara, 1959; Kopsch, 1940). This may seem odd at first sight, but it is exactly what was proposed in the “Jenenser Nomina Anatomica (JNA),” the revision of the first Nomina Anatomica of Basel (BNA; His, 1895), a revision decided upon at the meeting of the Anatomische Gesellschaft in Jena, Germany, in 1935 (Stieve, 1949). This revision of the Nomina Anatomica suggested to eliminate the optic nerve from the list of cranial nerves, and to file it among the structures of the diencephalon as “Fasciculus opticus” instead. In his 1949 comments, Stieve actually calls it “self-evident” that the optic nerve of the BNA could no longer be counted among the cranial nerves because it was not a peripheral nerve but “nichts weiter als eine Hirnbahn [nothing more than a tract of the brain]” (Stieve, 1949). This produced a gap between the first and third cranial nerves, and it was decided to fill this gap with the nervus terminalis. The JNA did not actually include numbers for the cranial nerves, but the position obviously implied that the nervus terminalis had thus become the second cranial nerve. However, the JNA was generally deemed a failure as it had produced anatomical terms that were philologically correct but partly inconsistent and often clumsy (e.g., today’s chiasma opticum was called chiasma fasciculorum opticorum), and it, therefore, never spread beyond German textbooks. The Sixth International Congress of Anatomy in Paris 1955, therefore, decided on a new version (the PNA), which for most parts reverted to the nomenclature of 1895 (Don ath, 1960) and newly classified the nervus terminalis among the olfactory nerves (see Table 1). Interestingly, the term “nervi craniales” (cranial nerves) appears for the first time in this 1955 revision. The BNA had called these nerves “nervi cerebrales” (i.e., nerves that leave the brain rather than the spinal cord), while the JNA suggested “nervi capitales” (i.e., nerves that innervate the head). Since PNA, the official terminology defines these 12 nerves as skull related. To define cranial nerves as nerval structures that penetrate the skull base solves the problem of the authors of the JNA, who did not want to classify central pathways like the optic nerve with peripheral nerves like cranial nerves III–XII. The more recent Terminologia Anatomica (FCAT, 1998) was the first official anatomical terminology to number the cranial nerves consecutively with Roman numerals and to give the nervus terminalis number zero. Vilensky suggests to call the nervus terminalis “nerve N” because Roman numerals come without a character for “zero” (Vilensky, 2014). This is historically and philologically correct, but as the abbreviation “N” in anatomy generally stands for “nervus,” “nerve N” becomes a rather curious term. For want of workable alternatives, I would therefore suggest to stick to the zero. We might see the nonRoman character “0,” an Indian invention, as a late terminological tribute to Susruta, the Indian surgeon of the sixth century BC (Loukas et al., 2010), who contributed to the advancement of anatomical knowledge long before the (Greek) Romans did.

When predicting item difficulty, is it better to ask authors or reviewers?

questions do we need to ask now in order to move the OES towards the collective vision? What relevant and credible information is needed to answer these questions? Step 5 pulled together the relevant information and a ‘learning huddle’ was held with members of the core team. The learning huddle had three objectives: (i) to make meaning of the information collected, (ii) to discuss what the core team is noticing or sensing in the system as a result of the work of the OES (emergent outcomes) and (iii) to identify any new or relevant questions that the core team thought important to ask in order to move the OES towards the collective vision. Step 6 involved ‘refreshing’ the evaluation based on the learning huddle discussion and Step 7 was the sharing of the evaluation findings to date with relevant stakeholder groups. What lessons were learned? The advantages to using this process include gaining a comprehensive understanding of the true value of the OES, making informed strategic decisions with confidence, and growing capacity within the department for learning and inquiry. That said, this evaluation approach should only be used in situations where the following is true: the primary focus of the work is programme growth and improvement (rather than solely accountability), there is flexibility to change or adapt the programme, there is a core team of people who can commit to the process as it requires dedication over a long period of time, and the culture of the organisation is one that is open to making mistakes and learning from them.