The Anatomist: A True Story of Gray's Anatomy

by Bill Hayes

  “Finally, just some basic etiquette for the weeks to come: No eating your lunch in here.” This elicits a collective ewwwww. “No music. Please don’t take any pictures. And try to keep your voices down. Laughter’s okay,” Dr. Sutherland adds. “We love laughter in the lab—it’s a great way to release emotions. But not at the expense of the wonderful people who’ve donated their bodies to our program.” He lets that sink in for a moment. “Okay, let’s get going.”

  A class orientation had been held the day before in a lecture hall downstairs. Afterward, we were invited to check out the lab and, as Dr. Sutherland had said in a masterful sweep of understatement, “to get comfortable with ‘the surroundings,’” by which he meant the reclining dead. About half the class had made the trip up to the thirteenth floor, myself included. I was anxious to put glimpsing the cadavers for the first time behind me. And I am glad I did.

  If that was the orientation, however, this is more like disorientation. I am not sure what to do or where to go exactly, so I grab the crisp new scrubs from my gym bag, pull them over my head, and join the large group being led by Dana Rohde, interim director of the anatomy course for the University of California–San Francisco School of Pharmacy, whom I had met earlier. Using one cadaver as a demo model, she gives a brief overview of the afternoon’s assignment; pauses to explain how to put a fresh blade onto a scalpel; does a quick scan to see that we are all wearing the mandatory rubber gloves; and adds finally, “I’ll be back to see how you’re doing in half an hour.” Dr. Rohde then stands there for a moment, wearing the look of a swimming instructor who finds her class still standing on the deck of the pool: Why aren’t you wet yet?

  Six of us arrange ourselves around cadaver number 4, but rather than looking at the naked female body lying before us, we all stare at one another.

  “I haven’t dissected anything since high school biology,” one of the three women admits, breaking the ice. “And that was a frog.”

  This seems like the right moment to make an admission of my own: “I should tell you, I am not a student here. Dr. Rohde gave me permission to come to your lectures and labs. I’m just going to be an observer.”

  All but one of them look as though they would pay to change places with me. Gergen, the exception, a tall, husky, hairy guy who says he has never dissected anything in his life, cheerfully volunteers to begin the dissection. Now, technically, it will be Gergen’s first cut, but not this body’s. Like all the cadavers used in this ten-week class in gross anatomy, it was worked on during a previous course. Instead of fresh bodies like those routinely autopsied on CSI—blue-lipped and gray but still lifelike—these are closer to something from a Discovery Channel special. The cadavers are shrunken like unwrapped Egyptian mummies. The skin, where still intact, is tan and leathery, and the exposed inner flesh is as dark and dried as beef jerky. The heads, hands, and feet are wrapped in strips of gauze, which gives the impression that they had been badly burned. As Dr. Sutherland explained during the orientation, the gauze serves two functions: it helps preserve the delicate parts for a longer period, and it also protects us, in a sense.

  “It’s usually most impactful to see the hands or the face,” he had said, treading carefully with his words, “because that’s really what represents a person’s identity.” When dissecting other parts, one quickly learns to dissociate, but this is much harder when you see the eyes or the mouth. Emotions can come up unexpectedly, he then added. “Sometimes, you’ll be dissecting away—maybe you’re halfway through the course—and then you’ll remove a piece of gauze and there’s a tattoo and you just stop cold. Or maybe you see nail polish.” Any individualizing mark is a stark reminder that this is not just a body but somebody. As Dr. Sutherland had explained, this is one reason why the first dissection is in a relatively neutral location, the thorax, otherwise known as the chest.

  Though I am the sole spectator here today, I take comfort in knowing I am well represented in history. Human dissection has been a riveting spectacle for centuries, and the curious, whether by invitation or paid ticket, have long pressed into crowded rooms, craning necks and breathing through perfumed handkerchiefs, to witness that first ghastly slice, then the next, and the next. In Europe, the need to create a space conducive to teaching, learning, and observing resulted in the Western world’s first “anatomical theater,” built in Italy in 1594 at the University of Padua. A steeply raked amphitheater that accommodated three hundred, it became the model for other facilities that sprang up at competing schools, including the College of Physicians in London. Always at the center was the dissecting table, with the first circle of spectators barely a blood spurt removed. At UCSF, I and my fellow novice anatomists stand not in a theater but in a no-frills lab. In order to get the best view of what is being dissected at our table, I have to perch on the rungs of a metal stool.

  Theater of Anatomy, London, 1815

  Our cadaver, who in life probably stood no more than five foot two, does not bear the classic “Y” incision of an autopsy (shoulders to sternum, then straight down the abdomen to the pubis). Instead, a kind of double doorway was incised in her chest: the skin cut across the collarbones as well as beneath the ribs—roughly marking the top and bottom of the thorax—and then sliced down the middle. Before making a new incision, we need to “unpack” the previous work. As Laura reads instructions from the lab guide, Gergen folds back the two large panels of skin, then grasps the edges of the underlying breastplate, a solid shield of ribs and muscles that had been precut with a surgical saw. Gergen lifts, and a fresh wave of fumes escapes from the cadaver, making all of us flinch.

  Peering down, I can see why the thorax was once known as the “pantry” of the body. It is a deep, squarish cavity packed full of various objects, one of which Gergen must now remove: a lung. He slips his left hand into the cavity and feels for “the root of the lung,” a short, fat tube that is not at the bottom of the lung, as one might imagine a root should be, but toward the top, connecting it to the windpipe. “Now what?” Gergen asks.

  Laura, who is as small and slim as Gergen is large, scrambles to find the next instruction. “Let’s see here—‘Cut through the root of the lung superiorly and continue inferiorly through the pulmonary ligament.’”

  “Translation?”

  “Top to bottom—slice it off—I think.”

  Although Gergen does the actual cutting, the rest of us, in spirit at least, help him hold the scalpel steady: Laura, Amy, Miriam, and Massoud are the fingers folded in around him, and I, opposite them, am the thumb. Gergen then steps back, indicating to Laura that she may do the honors. Biting her lower lip, she reaches into the thoracic cavity and, after a little tugging, frees the right lung. The size of a wadded-up T-shirt, it looks like a wet mound of gray taffeta. All six of us wear identical triumphant smiles, as if we have delivered a baby.

  But it turns out our baby is ugly. Dr. Rohde returns and points out that the cut was “too lateral,” which means the bronchus (an offshoot of the windpipe) is not clearly exposed. But she immediately tries to reassure us. “The only way you learn is by doing it, by making mistakes. Anyway, there are a lot of bodies here to look at, and, luckily, you’re not being graded on your surgical skills.”

  Before moving on to the next table, Dana instructs us on the next task: resection of a half-foot-long section of the phrenic nerve, a narrow fiber running through the thorax, a portion of which is visible now that the right lung is out of the way. Explaining the nerve’s primary function in the living, she breaks it down in simple terms: “If it’s damaged, you can’t breathe.” Likewise, if you sever your spinal cord above the level of the phrenic, she adds, you lose all use of this nerve. “That’s what happened to the actor Christopher Reeve, which is why he had to spend the rest of his life on a ventilator.”

  At this moment, everyone at our table is having the same illogical reaction: terror that we might render our dead body a quadriplegic. It is halfway through our first three-hour lab, and none of us feels any
detachment whatsoever.

  Massoud, taking over from Gergen, does not wear the expression of a lucky man, and yet the opportunity before him—to dissect and, yes, even make mistakes—truly is a privilege. To put this into perspective, Hippocrates, the “Father of Medicine,” for instance, never dissected a human body because the practice was forbidden in ancient Greek society. Aristotle, too, never broke this taboo, and, jumping ahead to the second century A.D., neither did the revered Greek physician Galen. Galen, whose writings remained medical gospel for fourteen hundred years after his death, had gained his knowledge of anatomy from dissecting pigs and cats. Brilliant but mistaken, he believed that animal and human anatomy were often interchangeable. And like a dropped figure in a checkbook registry, this error only compounded with time.

  Human dissection continued to be forbidden in virtually every society on through the Middle Ages. Not that it was not done, I’d wager—the dead body of a stranger surely must have proved too tempting for some unscrupulous practitioners—but how would you share your findings without implicating yourself? In parts of Europe, even dissection of animals eventually fell into disrepute because of its association with sorcery. In the year 1240, however, a radical change in policy took effect. Frederick II, emperor of the Holy Roman Empire, decreed that, for the sake of public health and the training of better doctors, at least one human body would be dissected in his kingdom every five years. For this bold move, Frederick II is credited with single-handedly pulling the field of anatomy out of the dark ages.

  By the beginning of the fourteenth century, human dissections were conducted as often as once a year at the top European universities. The corpses used, male and female alike, were almost always those of executed criminals. The leading anatomist of the time, Mondino dei Liucci (c. 1270—c. 1326), a professor at the University of Bologna, became the Henry Gray of the late Middle Ages. His dissection manual, Anathomia, completed in 1316, was used in nearly all medical schools throughout Europe for the following two hundred years. After the invention of printing, Mondino’s Anathomia went through thirty-nine editions, a number that the British version of Gray’s Anatomy has only just matched.

  Mondino earned a place in medical history by performing the first “properly recorded” dissection of a human corpse, but he is also remembered for sparking a revolution in the teaching of anatomy. Mondino systematized the process of dissection, providing a step-by-step method for exploring the human body. Following his lead, later pioneers would eventually overturn many of the fallacies of Galenism. In a sense, Mondino provided the map, allowing his successors to uncover a string of treasures.

  In the Mondino method, a human dissection followed a strict schedule dictated by a grim fact: the process was a race against putrefaction. In an age when cadavers were not embalmed, only the cold could slow decomposition, but only somewhat, so the procedure would be carried out during the coldest time of the year and at a rapid clip, over four successive days. Rather than beginning with the outer chest and progressively moving deeper into the body, as one would today, Mondino always dissected from the inside out, starting with the intestines, since they rotted quickly and smelled worst first. Seated above the cadaver on a pulpit, he would recite from his text while the actual cutting was done by a trained assistant. The students never dissected. A second assistant, called a demonstrator, would hold aloft or point out the body parts described. Incidentally, Henry Gray was a member of a similar three-person team at St. George’s and over his tenure filled each of these roles.

  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 acc
ess 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.