The Anatomist: A True Story of Gray's Anatomy (6 page)

Four

F
IVE DAYS INTO THEIR FIRST COLLABORATION, HENRY VANDYKE
Carter could happily report that Henry Gray liked the work he had done, and yet, he admits in his diary, drawing the spleen is “not easy.” In fact, the spleen is “not” a lot of things, I am finding, seven weeks into Gross Anatomy. It is not part of the digestive system, for instance, though it’s located in the abdominal cavity. It is not part of the urinary system either, though it’s connected to the left kidney. It is also not a part of the circulatory system, though its two main jobs are blood-related—recycling worn-out red blood cells and helping produce certain infection-fighting white blood cells. That these cells are called lymphocytes gives a clue to the spleen’s actual affiliation: the lymphatic system. The spleen is one last “not,” I should add. It is not vital. If it has to be removed due to injury or illness, the body can make do just fine without it.

The spleen is oblong and about half a foot long (fifteen centimeters) and, on the inside, spongy, with two kinds of pulp, red and white, which may have been the aspect Carter found difficult to render. Regardless of its actual appearance, I expect I will always associate the spleen with Denise, the giggly, freckle-faced, Japanese-American student who played the role of the spleen in one of Dhillon’s most memorable lectures. The abdominal cavity is frankly a big, twisting, confusing, crowded mess, and he wanted to show us how the parts fit together.

“Imagine we’re all sitting inside the abdominal cavity,” Dhillon began, sweeping his hands to indicate the entire rounded lecture hall. “See the slide projector up on the back wall there?” Everyone turned in their seats. “That is the belly button.” This got some chuckles. “The chalkboard behind me here is the vertebral column, the ceiling’s the diaphragm, the floor is the pelvic…
what
? Anyone?”

“
Floor,
” someone answered.

“Yes, the pelvic floor, very good, which keeps the poop from falling out.” Speaking above the boom of laughter, Dhillon added with faux grandeur, “Now, imagine that I”—he patted his generous belly—“I am the stomach!”

Next, he selected his cast of abdominal viscera and, one by one, positioned each in relation to himself: Gergen, the beefiest guy in the room, became the biggest organ, the liver, just to his right. (Someone gave Gergen a backpack to hold as a gallbladder.) Baby-faced Dan, tall and thin and sweet, became the pancreas and stood directly behind the stomach and next to the spleen, Denise, who peeked out from Dhillon’s left side. Right behind everyone, the inseparable gay couple, Andy and Wilson, held hands. They were the kidneys. By this point, the cluster looked like the world’s most awkward group hug, but Dhillon had just gotten started. Between the pancreas and the liver, he positioned the aorta (Amy) and vena cava (Ming), then added the ten different sections of the intestines, anus included, even though it’s technically not in the abdominal cavity (all the students in the second row were enlisted for this). Finally, he squeezed in the many interconnecting ligaments and membranes that keep all the abdominal structures stable. Spread arms and fingers worked this visual magic.

By the time Dhillon had finished, the cast of twenty-five had become a wriggling mass of simulated digestion. Somewhere in the back right, I could hear the spleen giggling.

Twenty minutes later and twelve floors up, in the lab, a dramatic scene, wardrobe, and mood change has taken place: Massoud removes the thick sheaf of abdominal muscles from our cadaver, and I, standing between him and Miriam, have rarely ever been so repulsed in my life. Lying exposed is a mass of glistening, fat-laden tissue that covers the entire abdominal cavity. This thick membrane is called the greater omentum (or, “large apron”), something I had not previously known existed. In our cadaver, it looks and smells like a rotten jellyfish. What lies underneath is grimmer.

Miriam begins by cutting open the stomach, which is not in the center of the belly, as I would have assumed, but tucked under the lower left ribs. She then reaches in, as if feeling for change at the bottom of a purse, and discovers a bolus of undigested food—meaning, this person had died soon after eating. This is the tipping point for me. My insides churn, the very definition of a visceral reaction, and I excuse myself from the table.

I am standing by the window taking in some fresh air when a squeal from the far corner of the room pulls me in that direction. Stephen and his partners have opened a gallbladder and found gallstones. “Here, Bill, do you want to feel one?” he offers.

Before I know it, I am rolling between my fingers what looks and feels like a black marble. This is
cholesterol,
calcified and mixed with bile pigment. These things can cause a lot of pain when they obstruct the flow of bile from the gallbladder. What’s more, people who have gallstones almost certainly have plaque-lined arteries, which is exactly the kind of life-threatening condition that can be treated by prescription drugs, in this case. No wonder Stephen, this aspiring pharmacist, is so fascinated. I tip the gallstone back into Stephen’s palm, thanking him for sharing.

To appreciate this dissection, I need to think more like a pharmacist, I tell myself. I need to
see
like a pharmacist. I also have to remember that
being
a pharmacist does not necessarily mean working at a Walgreens, Duane Reade, or Rexall. While some of these young people plan to become traditional community pharmacists, working at a neighborhood drugstore (or, as in the less traditional case of Andy and Wilson, opening their own), many will use their degrees as stepping-stones to larger plans. Stephen wants to go into drug development and join a major pharmaceutical company. Amy, on the other hand, is simultaneously earning a master’s in public health and hopes to work for the FDA. Theresa, who already has a master’s in criminology, plans to specialize in forensic pharmacology. Her entire focus will be to determine when drugs are a cause of death, whereas Miriam, who intends to become a clinical pharmacist, will work in a hospital as part of a surgical team. To all of these students, wherever a pharmacy degree may take them, this dissection will form the bedrock of their future work. The alimentary canal is, after all, the route traveled by every pill, tablet, capsule, elixir, syrup, or substance that can be swallowed, and knowing this part of the body backward and forward is essential to understanding how drugs are absorbed, dispersed, metabolized, and eliminated.

Back at my table, Massoud and the others are stuck in the mass of confusion known as the small intestine. Gray describes this part of our anatomy as “a convoluted tube,” as if he, too, had gotten lost here once or twice. The group backtracks to the stomach and begins again. It is easy to find the first part of the small intestine, the duodenum, because it is the first ten inches (twenty-five and a half centimeters) off of the stomach. (
Duodenum
comes from the medieval phrase meaning “intestine of twelve fingerbreadths.”) Here is where most ulcers occur. The remaining nineteen or so feet (six meters) of the small intestine is composed of, first, the jejunum, followed by the ileum, which eventually leads into the large intestine. Had we tipped our cadaver to the side, the intestines would not have just poured out, and neither could we have simply pulled them out, foot by foot, the way you see in gory movies. Connective tissue keeps the twisting mass contained in the abdominal cavity but able to roil freely during the digestive process.

The large intestine, about five feet (one and a half meters) in length, frames the small intestine on three sides and comes in four main sections: the ascending colon up the right shank; the transverse colon across the abdomen at the level of the bottommost rib; and the descending colon down the left, which then turns into the S-shaped sigmoid colon and feeds into the rectum. By any name, bowels are bowels and unbeautiful, but serve a necessary purpose. Within these coils is where water is extracted from what has been digested and what remains is turned into what will be flushed.

“Oh, Bill, did you see this?” Miriam asks, nudging a pinkie-sized flap of tissue that, in fact, I had not noticed.

“The appendix,” she says at the same moment I recognize it.

I love it when an anatomical term comes with a built-in mnemonic. True to its name, the appendix is
appended
to a corner of the large intestine. A handbreadth away is an organ that’s completely unmissable, the liver, filling the upper right abdominal cavity. Whether viewed in situ or displayed on a specimen tray, the liver is an impressive sight, large and smooth, with perfect lines and a broad surface. It almost looks sculptural. One can see why early philosophers and physicians were fooled by its appearance. Plato, in a dialogue on natural science and cosmology from the fourth century
B.C.,
asserted that the liver played a key role in the maintenance of the soul by keeping the organs of the abdomen in line. The liver did this through its smooth, shiny surface, which reflected images sent from the “divine psyche,” the immortal source of rationality housed in the head. Six centuries later, Galen called the liver the seat of life; hence its name, evolving from an ancient root,
leip,
associated with “life” or “living,” which later became
lifer
and, finally, the familiar term,
liver.
Galen believed that the liver produced blood—the life force—from digested food, which explained why the liver “clasps” the stomach, he wrote, “as if by fingers.” Further, the liver released into the bloodstream Natural Spirits, an incorporeal substance that provided the body’s mass.

In reality, this organ filters toxins and medications from the bloodstream; converts blood sugar into usable energy; produces and secretes bile, a substance that helps the intestines digest fats; and performs hundreds of other functions. But the liver also possesses a remarkable ability that can compete with the fantastical beliefs of old: alone among the major organs, it can regenerate. In a liver transplant, for example, if you remove half a liver from a healthy donor, the donor’s remaining organ will grow back to its former size. And, even more amazing, the half liver transplanted into a recipient will grow to the exact size of the recipient’s own original liver. Now, it is impossible to explain
why
the liver would do this. (As Dana would say, “In anatomy, you can’t ask
why.
It just
is;
that’s how we were made.”) But to me, it is hard not to see something of the miraculous in it. We are each meant to
be
a certain way, and our bodies make it so, as if predestination were encoded in our anatomy.

PONDERING HIS FUTURE
on the eve of his nineteenth birthday, H. V. Carter summed up his prospects in two sentences: “With energy and perseverance much may be done and without either, nothing can be done. Two roads: to mediocrity and [to] eminence.”

Which one would he take?

Mediocre or eminent: which would he
be
?

Though the occasion was special, the dichotomy was typical. To young Mr. Carter, as exacting as he is earnest, everything is black and white—and Gray. Henry Gray starts appearing in the diary almost every day after being promoted to house surgeon in late June 1850, two weeks into the spleen project. Carter goes on daily rounds with him and witnesses his bedside manner, no doubt, as well as how he interacts with medical students and fellow doctors. Less than a week goes by before Carter begins making inquiries about what it takes to become house surgeon; clearly, he has got a goal in sight. He approaches Dr. Tatum, Gray’s mentor, who says that it normally takes at least six years.
Six whole years?
Seeking a second opinion, he has the same conversation with Gray, with whom he has a growing friendship.
You
could do it in half that time, Gray tells him, paying the younger man a fine compliment—Gray, after all, had needed four and a half years to obtain the appointment. But in Carter’s mind, he had his work cut out for him. Compared to his friend, he saw many failings in his own character. He describes himself as “indecisive,” “very slothful,” “diffident,” “not confident,” and, over and over again, “idle.” Even after the busiest days, jam-packed with schoolwork, hospital work, and artwork, he reprimands himself. “Must work more.” “Must work better.” “Must be more exact.”
Must,
in fact, must be the most frequently used word in Carter’s vocabulary.