The Anatomist: A True Story of Gray's Anatomy (3 page)

Illustration from an edition of
Anathomia
by Mondino dei Liucci, c. 1493

By the final day of a Mondino dissection, the smell had probably risen to the level of olfactory bludgeon. For this reason, the University of Bologna made a special allowance to the anatomy department, providing a budget to purchase wine for the students and spectators at dissections—a little something to help deaden the senses, one gathers. (Interestingly, the cadaver, too, might have benefited from the alcohol, which, as anatomists would later discover, makes a pretty good preservative.) One final allowance deserves mention. In what may have been the creepiest way in history to earn extra credit, students at Bologna could bring in bodies of their own. But even in this case, they were not permitted to dissect them.

As I step back and watch Massoud, Laura, and the others finish exposing the phrenic nerve, I find myself preoccupied with how tiny our cadaver looks—smaller than any of the others in the room. For a moment, I even wonder if this could be a child, but I know that’s not possible; children’s bodies are almost never given to an anatomy program (instead, parents will commonly donate a deceased child’s organs for transplant or research purposes). A walk to the “Cause of Death” list posted on the back wall sets me straight. We actually have the body of a frail woman who was eighty-eight years old. She died of heart failure and had also had Alzheimer’s disease.

Returning to the dissection table, I take the opportunity to feel her lung, which Laura had placed beside her neck. This is the first internal organ I have ever held in my hands. Whereas I thought the lung would feel hollow and light, instead the tissue is dense, with the consistency of a wet loofah. The base of the lung is smooth and concave where it had nested upon the top of the diaphragm. I really want to see what the organ looks like on the inside. But that, I trust, will come with another class.

I fold back into the group as they reassemble the chest cavity and notice something startling: the gauze wrapping has fallen away from the cadaver’s right hand. The fingernails, a part of the body extremely slow to decay, are still those of a well-groomed little old lady—nicely rounded and buffed, as if she had just come from a manicure. I lift her wrist and the whole arm rises stiffly. I rewrap her hand in gauze, then help pull the drape over her body.

AFTER CLASS, I
cross Parnassus Avenue and move from the realm of rubber gloves to white cotton ones, from the dissection laboratory to the Special Collections Room of UCSF’s medical library. I have an appointment with a first edition. Up two flights of stairs, the jewel box of a room is climate-controlled and silent, and, save for the librarian and me, empty. Ms. Wheat retreats to a back room in her familiar way and reappears moments later. I love this almost ceremonial part of my visits, the way she approaches my table with the requested volume in her gloved hands, as if she were a sommelier cradling a rare vintage. With a whispered
thank you,
I nod in approval as she places before me an 1858 copy of Gray’s
Anatomy.

The book rests on a large foam pad, angled like a lectern but deeper near the center to minimize stress on the spine. For a nearly 150-year-old book, it is in amazingly good shape. As I admire the pristine brown leather cover, I pull on the thin white gloves Ms. Wheat has left me and can’t help noticing how similar they are to the ones my sisters each wore to their First Holy Communion. I crack open the cover and turn the first few pages. This releases the faint earthy smell unique to very old books, a smell I happen to like, a scent preserved from another time.

Although his book has assumed the mantle of a classic, Henry Gray wrote it for a most prosaic purpose: to satisfy a pressing need for new medical textbooks. The demand was driven by several factors, but the most compelling was the discovery of anesthesia in its earliest form, chloroform. Nowadays, when “going under the knife” is a phrase that’s slipped into casual conversation and surgery is entertainment on reality shows, it is hard to imagine how revolutionary it was to suddenly have the ability to safely put patients under, to be able to cut into their flesh without their feeling that burn of the blade. Prior to this innovation, the field of surgery was chiefly concerned with—as paradoxical as this sounds—
external
medicine, what the doctor could see or easily feel under the skin, whether this was a boil to lance, rotten tooth to pull, or gangrenous limb to remove. Since the patient was conscious, a surgeon had to be dexterous and, above all, speedy. With the use of anesthesia, operating theaters became far quieter, doctors could take more time, and an all-new terrain opened up. As never before, doctors had access to deeper, heretofore unreachable areas of the body. Consequently, the scope of what a medical student had to learn grew exponentially; hence, the need for an exhaustive encyclopedia such as Gray’s
Anatomy.

Of course, anatomy texts had been around for more than five hundred years by this point; Henry Gray was not inventing the wheel here. And in fact, several decent textbooks were already available. Quain’s
Elements of Anatomy,
for instance, was in its sixth successful edition at the time. But Gray had clear ideas on how to make a better book, and a commercially successful one. The main selling point would be its emphasis on
surgical anatomy
—applying anatomical knowledge to the practice of surgery. This alone would make Gray’s
Anatomy
a great buy—a practical text that would remain useful long after the student entered the professional world.

His author credit forms two lines on the title page, bold and capped:

HENRY GRAY, F.R.S.,
LECTURER ON ANATOMY AT ST. GEORGE’S HOSPITAL

For me, seeing it in its original form is equivalent to being formally introduced to this man whom, till now, I had known only from a distance. The introductions continue in the introduction itself, a section not reproduced in my copy of the book. Here, Gray acknowledges the contributions of two friends: Timothy Holmes, who helped edit the text, and Henry Vandyke Carter, who both executed the drawings and assisted with the many, many dissections required for the work.

I tear a piece of scrap paper to mark this page and nearly give Ms. Wheat a coronary. Her expression is somewhere between cat-in-bathwater and teacher-on-edge. With a pursed expression, she promptly delivers to my left hand a pile of precut page markers.

I had brought with me to the library my copy of
Gray’s
(a 1901 facsimile) so I could compare them side by side. What’s immediately obvious is that hundreds of drawings by a different artist were added to the later version, although, even without the benefit of credits, it is easy for me to tell whose work was whose. When the book was first published, the British medical journal
The Lancet,
typically not one to rave, praised it as the best anatomy treatise “in any language” and called Henry Vandyke Carter’s illustrations “perfect.” Indeed, they are perfect, both exquisitely wrought and functional. His great innovation was to place the anatomical names right on the parts themselves, like street names on a road map—in spots, terms even curve right along with the anatomy—something students found enormously helpful. By comparison with Carter’s originals, the added drawings look blunt and diagrammatic. The most striking difference, however, is the first edition’s lack of color, which I am surprised to discover I favor. Carter’s drawing of the man in profile—the image that first captured my attention—is more beautiful in the original, where it appears not on the cover but a third of the way into the text. Seeing it as Carter intended is like seeing a masterpiece restored. And the colored version—
how have I not noticed this before?
—now looks garish.

Not surprisingly, I find subtle text differences between the 1858 and 1901 editions; in the latter, words are substituted, sentences shortened, punctuation changed. As a result, the book, already clinical in tone, was made even chillier. In the original, Henry Gray often provided brief introductory remarks for each section, which set a welcoming tone. Forty-three years later, his remarks were gone.

One thing is exactly the same in both editions: the book comes to an abrupt conclusion. It is almost as though Professor Henry Gray, in the midst of lecturing, sees that he has gone past his allotted time. His words quickly grind to a halt—“…and receives a prolongation from it.” And that’s that. Class dismissed. In the first edition, however, two last words appear, in tiny print:

THE END
.

As I sit in the library, those two little words sound wonderfully ironic. Could Henry Gray ever have imagined what “The End” would begin, the long life his work would enjoy? Having never gone out of print, it has to date seen thirty-five editions in the United States alone. It has been translated into more than a dozen languages, been pored over by generation after generation of medical students, and sold millions of copies.

I try to imagine what was going through his head when, early in 1858, Henry put the finishing touches to his tome. I picture him sitting at a meticulously organized desk in the Gray family home on Wilton Street, where he lived alone with his widowed mother. The hundreds of handwritten manuscript pages are stacked in a neat tower, ready to be boxed up for his publisher, when the thirty-one-year-old gets bitten by whimsy. He pulls out a fresh sheet of paper and, with his most careful calligraphy, writes those two last words. He slips this final page into the bottom of the stack. He does not expect it to survive the editing process; this is his attempt at a little joke.
“The End”? Yeah, right.
A book ends, a story ends, a life ends. But the desire to study anatomy never will.

Two

I
N BOOKS ON HUMAN ANATOMY, THE SKELETON IS GENERALLY
either the end point or the starting point. The two Henrys, Henry Gray and Henry Vandyke Carter, chose the latter for their tome. “In the construction of the human body,” the text begins, “it would appear essential, in the first place, to provide some dense and solid texture capable of giving support and attachment to the softer parts of the frame; such a structure we find provided in the various bones, which form what is called the Skeleton.” Gray’s tone here, eminently reasonable and deceptively conversational, immediately draws the reader in.

The first drawing one sees is of a cervical vertebra, one of the seven bones that, stacked atop one another, form the skeleton of the neck. Typical of Carter’s style, the bone is rendered with a fine, delicate line and with perfect shading to show depth and dimension. Though elegantly drawn, I somehow doubt it is the kind of thing his mother had in mind when, years earlier, she dreamed that her firstborn son would become a famous artist. Eliza Carter reportedly had so hoped that Henry would follow in the footsteps of the great seventeenth-century Flemish painter Sir Anthony Van Dyck, known for his lush portraits of English royalty, that she chose Van Dyck as his middle name. On the day of young Henry’s baptism, however, the desired spelling was misentered into the parish registry as “Vandyke,” an error that endured. Regardless, he would come to use his full given name only rarely, preferring to go by the initials “H.V.”

Carter may have inherited his mother’s hopes, but his artistic talent came from his father, Henry Barlow Carter, a popular Yorkshire watercolorist known for his landscapes. In addition to H.V., born on May 22, 1831, the Carters had a daughter, Eliza Sophia, called Lily, and a second son, Joseph Newington. (Lily and Joe, born in 1832 and 1834, respectively, shared the same birthday, December 26.) The family lived in Scarborough, a seaside village in northeastern England, where Mr. Carter was an art instructor and artist in residence at the local library. What provoked the young H.V.’s left-hand turn toward medicine is not certain, but two strong influences have been identified. His uncle, John Dawson Sollitt, was the headmaster at his grammar school and possessed a keen interest in science, as did one of H.V.’s older cousins, yet another Henry—Henry Clark Barlow—who was a physician as well as, curiously, a Dante scholar. Following his completion of grammar school (the British equivalent to high school), Carter, fifteen, became an apprentice to a pair of Scarborough physicians and during these nine months learned the rudiments of country medicine. A young man, however, did not become a licensed practitioner in a sleepy place such as Scarborough. At sixteen and a half, H. V. Carter “came to town,” as he would later put it, moving by himself to London, the largest city in the world at that time and home to a number of medical schools.

Unlike a student entering medical school today who steps onto the educational equivalent of a moving sidewalk—a set course of study, logical and well organized, leading straight toward a medical degree—Carter had to follow an often circuitous path in pursuit of training. Still, at least a path had been paved. Just a generation before, there were no established guidelines for a young man seeking a medical profession, even in the influential city of London. Writing of that period, British medical historian Charles Newman notes, “The process was entirely unorganized—it was left to the student to decide on his own curriculum and to find out how it could be followed.” While improvements had been made by the time of Carter’s arrival, the system remained disorganized, albeit in different ways. Now, seventeen independent licensing bodies existed—the Royal College of Surgeons, the Society of Apothecaries, the Royal College of Physicians, and so on—each with its own accreditation criteria.

Carter’s father had arranged for his son to be placed with the Royal College of Surgeons, under whose purview H.V. became an “articled student of medicine”—that is, apprenticed—to a London doctor, Dr. John James Sawyer. This was a legally binding agreement, for which Carter’s father had to pay a fee of ten guineas to the RCS. In addition to on-the-job experience with Sawyer, H.V. would live with the doctor and his family over the next three and a half years.

Freshly articled and newly settled, H. V. Carter was then able to take his next big step in becoming a doctor: on May 27, 1848, he registered as a student at St. George’s Hospital Medical School and immediately plunged into full-time coursework. Coincidentally, as Carter was starting his education at St. George’s, Henry Gray, four years older, was in the last year of his. Though their momentous collaboration was still a decade off, it’s safe to say that the two men first met, at least in an academic context, in the last weeks of 1848. As was true of Mondino’s time, dissections were performed only during the coldest months, so Carter’s study of the human body did not begin until the start of the winter session. And, as fate would have it, Henry Gray had just been newly appointed as demonstrator of anatomy.

So did the two become fast friends? When did Gray learn of Carter’s artistic talent? Was the
Anatomy
their first work together?

Well, of course, Gray doesn’t say. While the historical record for the famed anatomist is silent, such is not the case for his lesser known colleague. In fact, in the time leading up to my first day of anatomy class, I had discovered that a trove of H. V. Carter’s diaries, letters, and other personal documents was stored at the Wellcome Library in London. The papers, which date from his grammar school days to the end of his long life, had scarcely been studied. With tact and a credit card, I was able to persuade the library’s archivist to have the first two diaries microfilmed for me, sight unseen, so that perhaps I, too, could witness life in London in the middle of the Victorian era and, through H. V. Carter’s eyes, hopefully get a glimpse of the inscrutable Henry Gray.

Only after I had placed my order did a sinking feeling hit: What if I could not read Carter’s handwriting? That doctors have notoriously bad penmanship can hardly be unique to our day and age. What if the diaries were impenetrable, and that is why Carter’s story remains largely untold? Just as worrisome: what if he had used his diary not as a repository for his feelings and experiences but as a mere date book, filled with nothing but class notes and study schedules?

Six long weeks later, my answer arrived by mail on a fat spool in a sturdy square box. I headed immediately to that last refuge of the antiquated technology of microfilm, the public library. Providing tech support and, if needed, moral support, along with me came my longtime partner, Steve.

Steve fed the thick, wide film leader into one of the brutish old projectors, and I, with fingers crossed, pressed the Forward button. First came the loud flapping sound as the microfilm struggled to catch onto the receiving spool, then the quieter hum as it sped through the projector. A long stretch of velvety blackness filled the screen and then a blinking brightness. I backed up to Part ONE.

The diary of H. V. Carter got off to a very promising start. In the opening lines, written in a large, childlike script, I got immediate answers to my first questions: why and when did he start keeping a diary?

A gift from his “Grandmamma,” it reads, the diary was “to be commenced May 22nd, 1845,” the boy’s fourteenth birthday, “when leaving Scarborough for school in Hull.” (Hull was a city down the coast where he would be a boarder at the grammar school headed by his uncle.) What immediately follows this text, though, is not the musing of a fourteen-year-old but instead a terse disclaimer written by Carter seven years later:

“I began my Journal at the above date or soon after and continued it for at least six months being then at School in Hull,” he explains, “but from an unpleasant occurrence happening at this time, the journal was altogether discontinued—the existing pages being destroyed—and was not resumed till the end of ’48 when I came to town. Since then, with but one exception,” he adds, “I have kept a continuous daily record….” His handwriting in this portion is barely legible—small and cramped as if, in the intervening years, the young man had folded in on himself.

Exactly what unpleasantness occurred Carter does not reveal, but, hazarding a guess, perhaps some school bully found his diary and threatened to divulge his secrets. This gave me pause. Was I violating H. V. Carter’s privacy, under the guise of research? At the same time, I felt that he could not have a more sympathetic reader. I, too, had started a journal at age fourteen only to rip it up a few months later. By destroying the pages, I could almost believe that the sinful thoughts I had recorded would cease to exist. I could then start fresh, my soul a blank white page. But like the young H.V., I continued to write. Over the years, I filled notebook after notebook and kept them as well hidden as I had learned to hide my inner self. In fact, I kept journals until my need to keep secrets finally ended when I came out in my early twenties. And yet, two decades later, I still have the journals, every last one.

Moving to the second page of Carter’s diary, I found him, precisely as he had noted, in London in December 1848, a seventeen-year-old halfway through his first year of medical school. From here, page after page of daily entries form weeks, then months, then years. Whirring through the microfilm, I stopped every now and then, like a crow drawn to a shiny object, and picked up pieces of his story. I found bright bits, but dark ones, too, admissions of success but also of failure and sin. His handwriting was sometimes loose and legible, but most often it resembled long strings of tiny knots. Here and there, familiar names and places popped out. Most exciting to see was how, beginning in 1850, the black-on-white pages became sprinkled with
Gray
s, the name always written in beautiful cursive. I had found what I had been hoping for—Henry Gray lived on these pages—but there was more. The sprawling paper trail left behind by H. V. Carter would lead me not just through the winding corridors of St. George’s and into the dissection lab on nearby Kinnerton Street but, most intimately, most tellingly, deep into the troubled heart of a gifted man of science.

“
YOU’RE
BACK
?” MASSOUD
says when I join him at the dissection table on day two of class. His dark, bushy eyebrows have raised to the point of looking painful. “I cannot believe you’d come here voluntarily.”

I laugh and admit he has a point—most people would not choose to spend an afternoon disassembling a body, a gruesome business made more so by the harsh embalming chemicals. But to me, this is a small price to pay for seeing the extraordinary, the inner architecture of the human form.

Massoud and his classmates, obviously, do not have a choice about whether to be here. Each must pass this anatomy course in order to graduate, as must those enrolled in UCSF’s dental, physical therapy, and medical schools. As to why it is mandatory for pharmacy students, that is easy to understand. To grasp the basics of how medications work within the body—from, for example, the placing of a pill on the tongue to its passage down the throat and course through the digestive, then circulatory systems—one must first grasp the fundamentals of how the human body is constructed. Hence, ten weeks of Gross Anatomy,
gross
coming from the German for “large” and referring to structures of the body that are visible with the naked eye.

Dr. Rohde approaches our table and, before even saying a word, instantly captures our attention: she is holding a human heart. “The most
amazing
thing we do as human beings occurs the moment we’re born,” she goes on to say. “We have to learn how to breathe on our own.” And for the rest of our lives, the heart bears a scar of this life lesson. One of the goals for this afternoon’s lab is to find this mark in our cadaver.

Massoud and I take turns reading aloud from the lab guide as Gergen, Laura, and the three other students undrape the body and align the dissecting instruments. To my surprise, Amy, the least assertive of the bunch, agrees to perform the dissection. Amy is just over five feet tall, stocky, with bobbed brown hair and funky rectangular eyeglasses. For added height, she steps onto one of the wood risers positioned around the table, then picks up a scalpel and, following our instructions, makes a large, neat “cruciate cut”—cross-shaped—atop the pericardium, the opaque protective sac that encloses the heart and helps hold it in place. The pericardium is composed of multiple layers, with the final, thinnest layer adhering ever so lightly to the organ itself.

Amy slides her finger into the center of the cut and folds back each flap, exposing the heart. She reaches for a larger blade. Amy looks so comfortable using a scalpel that I cannot resist asking if she’s ever thought about being a surgeon rather than a pharmacist.

“Not until now,” she answers with a smile.

Next, Amy slices through the six blood vessels entering the heart and the two exiting it. Then she puts down the knife, grasps the heart with both hands, and tugs, uprooting the organ from its bedding in the chest. She places it on a towel-lined tray to her left.