The Anatomist: A True Story of Gray's Anatomy (4 page)

The human heart has four chambers, but it is not obvious from the outside where each is located. Six noses press in for a closer look. Subtle grooves on the exterior of the organ serve as landmarks, and we are able to orient ourselves. The right and left atria, as their names suggest, are the two cavities up on top. The right and left ventricles form the lower portions of the heart.

Amy proceeds with the final incisions. Using a fine blade, she makes a small doorway into the right atrium and, turning the heart over, a larger opening in the left ventricle. Our heart now has a front and back door, but there also seems to be a flooding problem. Dr. Rohde—Dana, as she insists we call her—has been observing how we are doing, and she suggests that someone take the heart to the sink and rinse it out.

I volunteer.

With an air of quiet ceremony, Amy places the heart into my gloved hands, and I instinctively draw it to my chest. My own heart instantly speeds up. The lab has never seemed more crowded, the distance to the big stainless steel sink never more vast. I feel as if I were carrying the most fragile thing in the world, which is silly, for our heart is already broken in a sense; our cadaver had died of heart failure.

Once I begin rinsing the heart, cradling it in one hand while rubbing it with the other, I relax. It is tough and rubbery. The aorta, the major artery emerging from the heart, is a severed garden hose. As I feel the smaller vessels, white and gristly like the roots of a turnip, I understand how the word
heartstrings
came to be, based as it was on the belief that stringlike tendons keep the heart in place and can be tugged or plucked like harp strings, eliciting different emotions.

What washes down the drain is a grainy brown paste, coagulated blood from inside the heart. I pat the heart dry and return to our table.

With Dana as our guide, we examine the four chambers in the same order blood passes through them, beginning with the right atrium. This is where blood is received from two veins—carriers of deoxygenated blood—the superior vena cava and the inferior vena cava. (
Superior
means topmost and
inferior,
bottom, terms that we would come across again and again.) The right atrium pumps blood into the ventricle beneath it, which pumps it into the lungs. Blood returns to the heart via the pulmonary veins (the only veins in the body that carry oxygenated blood) and enters the left atrium, which pumps it to its partner below. The wall of this last chamber, the left ventricle, is the thickest and strongest of them all; it has to be. With each pump, the left ventricle propels blood up through the aorta and out through the body’s miles and miles of arteries.

But before supplying blood to the whole body, Dana notes, the heart does something very wise. “Does anyone know what it is?”

She is answered by six shaking heads.

Dana points to two slim vessels emerging from the base of the aorta and snaking down the heart’s surface. These are the right and left coronary arteries. In what makes perfect sense now that it’s pointed out, the first destination for fresh, oxygen-rich blood is here. “Remember this phrase,” Dana tell us: “‘The heart feeds itself first.’”

Remember
it? I’d like to contemplate it. But there is no time. Dana and the team are already focused on the right atrium. Through Amy’s doorway, they find the scar Dana had mentioned earlier, a thumbprint-sized indentation.

“In utero, this used to be a hole,” Dana says. During fetal life, blood passes not into the lungs but directly from the right to the left atrium through this shortcut. Though the baby is not breathing in a technical sense, it is getting plenty of oxygen, drawing it from the mother’s bloodstream through the placenta.

“But the shunt becomes obsolete at birth,” Dana continues, “when a newborn, gasping for air, uses its lungs for the first time.” This single act radically changes the pressure within the circulatory system, channeling blood
into
the lungs rather than away from them. No wonder a newborn howls. Within hours, the hole begins closing up, leaving behind this fossil of fetal life, the fossa ovalis. In some babies, Dana adds as we each take turns examining it, the shunt does not heal properly, leaving an actual hole in the heart, which has to be surgically repaired.

You cannot hold a human heart without questioning how it ever became known as the center of emotion or, as the grand sixteenth-century French surgeon Ambroise Paré once described it, “the chief mansion of the Soul, the organ of the vital faculty, the fountain of the vital spirits.” To me, the heart does not look or feel like anything but what it is, a tough, muscular pump. But wait, not so fast.

“Let me show you one last thing,” Dana says before moving on to the next group and the next body.

Massoud, Amy, and the rest of us crowd around her as she lifts up the cadaver’s heart and pulls the doorway into the right atrium as far back as it will go.

“Now, unfortunately, you can’t actually
see
it,” Dana says, “but, right inside
here,
where the superior vena cava enters the right atrium”—she points to a spot at the top of the fold—“right at that ridge is a little area where a cluster of cells is embedded. It’s called the sinoatrial node, or S-A node, but it’s known as the
pace
maker.” She lets that sink in. “This is where your heart’s speed is set.”

While she explains how the S-A node works—electrical signals generated by these cells spread to other cells across the heart, causing it to contract, to beat—I find myself dazzled by this perfect meeting of anatomy and metaphor. In the human body, the node is positioned right under the sternum, dead center in the chest. So, in a sense, this truly is where feelings such as terror, love, and elation are first felt—where your heart starts to race, pound, flutter.

Looking up, I notice that Amy is doing exactly what I am doing: we both stand with a hand at the center of our chests, instinctively feeling the moment. Here, right here, is where wonder begins.

Three

“I
HAVE TO SAY, KIDNEYS ARE ONE OF THE
SADDEST
-LOOKING
creatures!” laments Dana during a lab presentation midway through the ten-week course. I have to agree. The sickly gray organ, which she had just removed from a demo cadaver’s lower back, looks pockmarked, blob-shaped not kidney-shaped, and, indeed, sad. Though larger, it reminds me of a testicle, or at least the testicles we had studied a couple of weeks earlier. Do I detect a family resemblance?

Indeed, in males the two
are
connected, not directly but venously, Dana goes on to explain. Bridging the twelve or so inches from the left testicle to the left kidney is the testicular vein, which feeds into the renal vein as blood returns to the heart. This particular anatomical arrangement occurs only on the left side.

“In fact”—Dana cracks a playful smile—“in fact, this may explain why the testes hang unevenly.”

The men in the group share a nervous chuckle.

“You know what I’m talking about,” Dana says matter-of-factly. “Usually, the left testicle hangs lower than the right. Right?”

One could almost see the wheels turning as the assembled males each perform a mental inspection of their underwear.

“Right,” I volunteer on behalf of my shyer classmates.

“Well,” Dana continues, “this is likely because the left renal vein runs between two high-pressure arteries, so it may get slightly occluded—or squished. Less blood can travel through it, so the blood pools down in the left testicle, making it a little heavier than the right one.”

Now here’s some juicy small talk for a lagging dinner party,
I can’t help but think.

“Okay, let’s move on now,” Dana chirps, drawing our focus back to the object in her gloved hand. The “pitiful appearance” of kidneys is deceiving, she notes; these are strong, resilient organs, capable of impressive multitasking. They not only filter waste and toxins from the blood but regulate urine excretion while simultaneously maintaining the body’s electrolyte and fluid balance. If one kidney is removed or fails, the other will pick up the slack and do double duty.

The kidneys also provide a perfect illustration of an age-old anatomical truth: the body is designed to protect itself, not to be easy to dissect. As Henry Gray noted in his precise fashion 150 years ago, the kidneys are situated between the back of the abdominal cavity and another eight separate structures, including two powerful back muscles, and are “surrounded by a considerable quantity of fat,” even in the lean. All of which makes finding a kidney in a cadaver tricky. The best method, Gray advised, is not to go through the abdomen but to flip the body over, count down to the last rib, drop down another three-quarters of an inch (about two centimeters), then make your incision there.

Before rotating to the next group, Dana shows us the proper way to open up a kidney, carefully splitting it in two lengthwise. Like a pomegranate, whose leathery rind belies its jewel box interior, the kidney is spectacular on the inside. Each half is lined with the small chambers and pyramid-shaped tissue of the organ’s filtering system. Once everyone has taken a close look, we break up into our smaller groups and return to our cadavers. The goal: to replicate what Dana had so nimbly demonstrated.

As an observer, I have the option to move about the lab, from cadaver to cadaver, from group to group. (This is how I’d finally met the Woman in the Gas Mask from the first lab. Beneath the hazmat headwear was a lovely person named Iris, who is pregnant, it turns out, and, on the advice of her obstetrician, takes the extra precaution for her baby.) Although each lab lasts three hours, students are free to leave as soon as they finish the day’s assignments, and most of them do. But I like to stick around until the last body is re-draped. The whole experience has quickly come to seem normal to me; friends beg to differ, however, when I mention I am attending a course in anatomy.

“You mean, with bodies?” is always their first response. “Actual dead bodies?!”

What’s missing from their mental picture, I have come to understand, is the larger context. Just as a person who has never before stepped inside a church could gather from the altar and hushed candlelit atmosphere that it is a place of worship, so, too, could one enter the anatomy lab for the first time and readily grasp its purpose. Chalkboards line the entire back wall. Bookstands, poised at every table, hold identical manuals. Display cases and neatly labeled drawers contain anatomical models and specimens. Most important, though, is what happens about ten minutes into each lab: the instructors enter, at once transforming the space into a learning center of crackling vitality.

In putting together a team for the course, Dana’s first move was to coax back from early retirement the man she considers one of the leading anatomists in the United States, Dr. Sutherland. Tall and lanky, with silky white hair, Sexton dresses for comfort in sneakers and khakis and always wears whimsical neckties—one has dancing skeletons on a blood-red field. The antithesis of a dour anatomist, Sexton is sunny and self-deprecating, and in the lecture hall, a bit of a klutz, which is actually quite endearing. His clip-on microphone often falls off; he has trouble finessing the overhead light dimmer; his slides sometimes come up sideways (we all tilt our heads obligingly). The man obviously knows anatomy backward and forward—or, forgive me, posterior and anterior, as well as medial and lateral, superior and inferior, and in every other anatomical position—but he also makes it entertaining. In summing up the core behavioral impulses regulated by the sympathetic nervous system, for instance, Sexton once told the class: “Just remember the four
F
s: Fight. Flight. Fear. And—who knows the last
F
?”

Puzzled silence.

“That’s right,” Sexton said with a knowing nod. “Sex!”

Sexton brings the same exuberance to the lab, where, like his fellow instructors, he roams from group to group, answering questions and giving impromptu lectures. Each teacher has a different style. Dr. Nripendra Dhillon—Dhillon, for short—is the third of the trio of senior instructors and a master of visuals. I mean this both literally—he will often sketch on any nearby chalkboard, whether in the lecture hall or lab—and metaphorically. Lecturing on the intrauterine development of male reproductive organs, for instance, Dhillon made the descent of the testicles through the fetal body sound as dramatic as Odysseus’s epic journey home from Troy. With his deep, melodic voice, Dhillon recounted how the testes actually develop in a pocket of fat on the fetus’s back, behind the kidneys. But at around the ninth week of fetal life, these delicate little, well,
balls
ship off. Traveling separately but to a similar map, they slowly traverse the lower abdomen, pushing through layer after layer of abdominal tissue, acquiring new coats as they tunnel to their final destination: the scrotum. Though any man who has been kicked in the groin might not think so, these added layers actually provide protection. To make sure this journey was ingrained in our memory, as Dhillon spoke, he pulled successive, colored latex gloves over his right hand to represent each new layer—purple, green, pink, and finally, blue—each time balling his fingers into a thick, rubbery fist.

Two teaching assistants round out the team. Because Christy and Aaron were so recently students themselves, they are especially helpful in sharing mnemonics and other time-saving study tips. Of all the instructors for this course, though, Dana herself has made the strongest impression on me. In what I take as the highest form of flattery, she never treats me like an observer but as one of the 121 students in the class, even grilling me good-naturedly in the oral pop quizzes she sometimes springs during lab. Given her obvious enthusiasm for the subject of anatomy, I was surprised to learn, though, that Dana had never set out to become an anatomist.

“I’m definitely an ‘accidental anatomist,’” she told me one afternoon as we chatted on the way up to lab. After earning a B.S. in nutrition, a master’s in biology, and a Ph.D. in physiology, Dana had planned to go straight into medical research. But there was a surprise on the menu: an offer of a teaching job landed on her desk—UCSF was seeking a physiology instructor—and it was unexpectedly tempting. She accepted and was amazed to find how much she enjoyed teaching. Then she met Sexton and realized she would also like to teach the subject her new friend was so passionate about. He thought this was a fabulous idea; in fact, the anatomy department had an opening coming up. But first, Dana would have to turn herself into a great dissector. Sexton became her mentor. He spent hours and hours of extra time helping her learn how to perform the most difficult dissections. The greatest lesson he taught her, though, was one of aesthetics: how to make dissections beautiful.

“For a year, I was here
all
the time dissecting,” Dana said once we had reached the thirteenth floor, “even every Saturday night. That’s the way you learn anatomy. You sit down with a dissection manual and a cadaver, and you just slowly go through everything.”

I WOULD LOVE
to have been an observer as Henry Gray learned the art of dissection. Colleagues who remembered him as a student invariably recalled a “most painstaking” and “methodical” worker but left no more telling details or anecdotes in the historical record. Fortunately, however, I am able to reconstruct the setting where the young Mr. Gray spent hundreds and probably thousands of hours quietly following his passion.

A fifteen-minute walk from his family home on Wilton Street would have brought an eighteen-year-old Gray to the north end of Kinnerton Street, to the building where St. George’s anatomy courses were taught. In what he and his classmates probably found a dubious comparison, the premises were often likened to the inner architecture of the human ear. The building was set well back from the street, and, just as the ear canal leads to the eardrum, one passed through a long, narrow alley before reaching the main door. Completing the analogy, the school’s circular anatomical theater represented the spiraling cochlea at the innermost part of the ear. Lecture halls, an anatomical museum, and an impressive dissection lab rounded out the floor plan.

That Kinnerton Street was a good four blocks from St. George’s Hospital was seen by the medical school administrators as a significant drawback but also a marked improvement over the previous accommodations. When the hospital established its school in 1829—sixteen years before Gray’s enrollment—the board of governors declared that anatomy would not be taught on the hospital’s grounds themselves but close by. Right across the street, in fact. An excellent independent anatomy school had just opened and could easily accommodate the St. George’s students. What could not have been foreseen, however, was how one of the directors of the anatomy school, James Arthur Wilson, would constantly come to loggerheads with hospital administrators. A bilious-sounding character who went by the nickname Maxilla (the anatomical term for the upper jawbone, inspired by his initials, J.A.W.), Dr. Wilson was described with admirable delicacy by one historian of the period as a man “somewhat over-conscious of his own excellencies.” After one too many quarrels with Maxilla, St. George’s chief surgeon, Benjamin Brodie, ended the association between the two schools and, in 1834, financed the purchase of the Kinnerton Street facility.

By the time Henry Gray began attending classes there in 1845, Dr. Brodie had retired as surgeon and anatomy instructor but, at age sixty-two, continued to practice medicine and was regarded as one of England’s leading medical authorities. As writer James Blomfield observes in his history of St. George’s Hospital, Brodie had attained a degree of public acclaim rarely seen nowadays: “It is difficult for those who live in the present day, with specialists for every kind of complaint, to imagine the position of a man like Brodie. He was consulted by patients of all ages and upon almost every conceivable form of accident or disease.” One famous case involved a gentleman who, in a conjuring trick gone awry, had accidentally inhaled a half-sovereign coin, which then lodged in the man’s upper right lung. However, it seems that the true performance did not start until Dr. Brodie’s arrival. Immediately, he turned the patient, Mr. Brunel, upside down, a feat made relatively easy by the man’s owning a “revolving frame,” which I will assume was like a knife-thrower’s prop: a circular board to which, under normal circumstances, a lovely assistant would be strapped at the wrists and ankles then spun while knives are hurled. Upside-down-ness did not, however, help Mr. Brunel cough up the coin. Rather, the object plugged his larynx and he began to choke. With a confident slice of a blade, Dr. Brodie opened the man’s windpipe but, even with forceps, could not dislodge the half-sovereign. Another spin on the frame, however, did the trick. Gravity, a smack to the back, and a fortuitous gag reflex caused the coin to drop quietly into the man’s mouth. In tribute to the doctor’s calm under fire, the half-sovereign and the pair of forceps became one of the exhibits in the St. George’s Pathology Museum. As for Mr. Brunel, I can only hope he had the good sense to move on to card tricks.