The Anatomist: A True Story of Gray's Anatomy

by Bill Hayes

  She then adopts the classic pose of deep thought—chin resting on fist—and the air is immediately clear. Of course. But then—

  “Well, that’s not literally why.” She explains that mental actually comes from mentum, the Latin word for “chin,” but by this point, the mnemonic has stuck.

  “Now you’ll never forget it.”

  I have come to love this quality about Dr. Topp—Kim, as she has said we can call her. She is pro-mnemonics, pro-etymologizing, pro-whatever-it-takes to get you to remember the correct anatomical term, which I consider a very Henry Gray–like trait. He often supplies in his text the derivation or translation of terms as well as memorable visual descriptions. At the same time, though, this makes Kim the polar opposite of Dana, who is anti-mnemonics. Too often students use them as a crutch, as a shortcut that bypasses true understanding, Dana believes. But the two instructors are of one mind when it comes to the end result. If the phrase “Tom, Dick, And Nervous Harry” helps you remember the Tibialis posterior muscle, the flexor Digitorum longus muscle, the posterior tibial Artery, the tibial Nerve, and the flexor Hallucis longus muscle—the anatomical mouthful that converges in the lower leg—that’s fine, but don’t stop there. You have also got to be able to identify these structures in a body, know their function, their point of origin, and so on. As for myself, once learning becomes knowing, mnemonics become superfluous, I have found, and at the end of the day, nothing makes knowing come faster than doing a dissection yourself.

  I make the first cut for the four of us, a shallow incision from the top of the forehead down to just below the Adam’s apple. In a sense, this is like the imaginary line drawn down the center of a room that siblings must share—Becky and Jenny have their side, and Rachel and I, ours—but there is no rivalry here. Indeed, we share a bond forged by the intensity of what lies ahead: taking apart the face.

  Becky and I wield the scalpels for our teams. We both start at the same place, the skin at the cleft of the chin, and cut in opposite directions. The underlying bone here is the mental process. About an inch below each of the lower canines (the pointiest teeth of the lower jaw) is a tiny hole—the mental foramen—through which passes a tiny nerve, the mental nerve. We burrow for our respective holes. The nerve at each site supplies the lower jaw and lip, and when anesthetized during a dental procedure, for instance, causes localized sensory loss. Becky finds hers first, though I am soon behind. Each looks like a threaded needle, a small white fiber poking through a tiny eye.

  The next procedure is more delicate: exposing the facial artery, the major blood vessel supplying the face. Just as Henry Gray describes, “This vessel, both in the neck and on the face, is remarkably tortuous,” though, for the dissector, “torturous” could apply as well. An offshoot of the carotid, the facial artery starts in the neck, curves over the mandible, gives off branches to the lips and nose, then terminates at the inner “canthus” (from the Greek kanthos, meaning the corner of the eye). For Becky and me both, dissecting its winding branches takes considerable time and care. But once finished, what is revealed is far more than the twisting vessels themselves. Her side and my side mirror each other, an unexpected and remarkable display of the body’s inner symmetry.

  Next, we go our separate ways. This is the last lab of the course and, for the students, a chance to review areas of difficulty before the final exam. Rachel and Jenny head to the feet and Becky focuses on the brachial plexus. For me, this is a last chance to explore. I decide to examine the TMJ (the temporomandibular joint, also known as the jaw joint), a dissection we’d not had time to perform.

  I immediately hit an obstacle: the ear.

  The lab manual contains no instructions on how to remove an ear, so I operate on instinct only. I pull the pinna away from the scalp and slice in a slow circle. I dig at a sharp angle as if cutting a weed at its root. This proves startlingly effective. The ear comes off in one piece, and now I face a dilemma I had not anticipated: What does one do with an ear?

  Becky suggests I just throw it away, but that seems a little rash.

  “You could send it to someone,” Jenny offers wryly, making an allusion to Vincent van Gogh, who put his ear in an envelope and gave it to a prostitute for safekeeping. (Wasn’t her name Rachel?) For now, I fold the ear inside a towel and set it aside.

  Where the ear had been is now a hole in the head the size and shape of a kidney bean. This is the entrance to the ear canal, which runs just posterior to the TMJ. No wonder my clicking jaw sounds so loud, I say to myself. For many years, I have had what’s officially called TMJ disorder—TMJ, for short—a catchall phrase for various problems at this juncture of two bones. Mine, exacerbated by teeth grinding while I sleep, mainly manifests as a pop or click whenever I yawn or chew or open my mouth too far. In my head, the sound is huge. I am always surprised people don’t hear it.

  Having TMJ has made me hyperaware of my jaw, which, for the first time in my life, I am finding to be an advantage. The clicking is like a TMJ sonar pinging in my cheek, guiding my hand as I dissect. I cut back the parotid duct and gland, then gently slice through the powerful muscles of mastication. Next, alternately feeling with my fingers and using both the blade and the butt of my scalpel, I peel off the layers of fascia covering the joint itself. This is like peeling the skin from several stubborn cloves of garlic—tedious work, but I am utterly absorbed. I am a ping hunting a pop to its source.

  After almost two hours, I have exposed a near flawless specimen of the temporomandibular joint, including one of its most delicate features: the tiny cartilaginous disk that acts as a kind of shock absorber between the temporal (upper) and mandible (lower) bones. When this disk is damaged or, as in my case, abraded, TMJ disorder results.

  Stepping back from the lab table to appraise my work, I have no qualms about praising it aloud: “That is beautiful.” My lab partners heartily agree, as does Kim, who moves about the room telling other groups to come see my dissection. I am doing a final cleanup of the surrounding tissue when I see over my shoulder a wash of inquisitive faces. They have been quietly looking on, as if I were a sculptor brushing the dust from my latest work and they did not want to disturb me.

  “Nice job,” Casey remarks, breaking the silence. “How’d you do that?”

  With that, I become the go-to guy for the TMJ. Three groups invite me to their tables, where I tug at ears and talk through the procedure.

  By the time lab is over, I feel as though I have truly graduated from this course in anatomy. Even so, I am not content. Too many gaps in my knowledge—mental foramens of the metaphorical kind, to coin a phrase—remain to be filled. I have never studied the brain, for instance, and I am still trying to work my way through the nervous system. Kim suggests that I take one last anatomy course—this one, for medical students. She promises to e-mail me the details as well as an invite to a postfinals celebration party she would be throwing at her home in a couple of weeks.

  NEARLY EVERY STUDENT comes, a testament to the fact that I was not alone in the affection I had formed for Kim. The sole absentee, Rachel, had opted to take the course as an incomplete rather than risk getting a failing grade. She will have to retake PT anatomy next summer. Becky and Jenny got As, though, as did most of my earlier table mates. As it turns out, I had gotten a passing grade of my own: Kim had used my TMJ dissection in the lab portion of the final, where test cadavers have numbers pinned to specific parts. Name the muscle at pin A and describe its role in the movement of the TMJ.

  “You saved me from doing that dissection myself,” Kim says, clinking a Snapple bottle to my Heineken. “So, thank you, Bill!

  “Come on,” she adds, “it’s time for a tradition.” Sam has set up a digital camera on the deck railing for a class photo in the backyard. He sets the automatic shutter, then hops down and squeezes in next to Kim and me.

  Click.

  In the moment, I cannot help but flash on the photograph that launched me on this journey six months ago—Henry Gray and his students in the
St. George’s dissecting room. I look at that collection of faces several times a day, as I have made the photo the wallpaper on my computer. It never fails to seize my attention. I no longer zero in only on Henry Gray but notice other characters: the gentleman seated directly to Gray’s left, for instance, who, with his muttonchops and formal black coat, looks like the heir to a cough-drop fortune; and, just behind him, the younger fellow, arms crossed at the wrist, who appears to have lost his left hand. Then there are the two scamps at the very back who stand on either side of a human skeleton. Is the one on the left holding the skeleton’s hand? But what I mostly see in this picture now is a missing person—H. V. Carter.

  By the time this photo was taken, March 1860, Carter was no longer the demonstrator of anatomy. He was no longer even affiliated with St. George’s Hospital or, for that matter, a resident of London. In fact, he would not come to call England his home again for thirty years.

  What had happened in the interim? Where had Carter disappeared to and why? Well, the full, tortuous story comes complete with a torrid scandal straight out of a Victorian novel. But first things first. The two Henrys still have a masterpiece to create. And just two weeks into their collaboration, Henry Vandyke Carter has hit a major obstacle.

  Eleven

  “[HAD A] LONG CHAT WITH GRAY, WHO CANNOT UNDERSTAND that anyone should really wish to work and yet not be able to begin,” Carter confides to his diary on January 8, 1856. “He is altogether practical—‘Do it!’—his aim ‘money,’ chiefly. As for self, need energy and right counsel. Mind certainly not healthy or balanced, and time very indifferently spent.”

  This sounds less like a chat and more like a spat. Every time I read this entry, I feel as if I am right there as these two enact a fascinating early scene in the genesis of Gray’s Anatomy. Each Henry plays his role to a T: Gray, the taskmaster, is all business, while Carter is the temperamental artiste who seems to have misplaced his muse. Oh, he sounds so grieved, so misunderstood! But he also sounds troubled. The line Mind certainly not healthy or balanced always stops me cold. Though I can make no claims to a definitive diagnosis, this young man seems gripped not just by artist’s block but by a debilitating depression as well.

  That H. V. Carter was prone to dark moods had been clear from the start of his diary. To some extent, I had taken this tendency with a grain of salt, as I know that sometimes, on the pages of one’s diary, feelings get overblown, the better to puncture and purge them. Also, I had noticed a predictable pattern to Carter’s moodiness. He suffered from a condition I had myself as a young man, what I call the Sunday syndrome. His entries tended to be at their longest, most heartfelt, and most angst-ridden on Sundays, the day when he set aside worldly matters and took time to reflect and attend church. The sermons delivered by the ever-stalwart Reverend Martin were rarely less than “capital” or “excellent” and always left Carter with a boost of fresh resolve to be a good, moral, industrious person. But this was the spiritual equivalent of a sugar high. By the end of the day—diary-writing time—he would crash and burn, convinced that he fell far short of the ideal Christian he knew he should be. Such was his misery that I’ve often thought he would have been a happier person if the week had only six days.

  As the darkness slipped into his diary more and more often, I could no longer write it off to Sunday. With the start of 1856, Carter’s moodiness becomes the blackest melancholy, and the twenty-five-year-old writes of being fitful, fatigued, and overtaken by lethargy, classic physical symptoms of depression. Carter knows he is not well but is at a loss for what to do. “Am right down [sic] helpless when ought to help self. No abiding effort. Must be compelled, not invited.”

  Remarkably, he pushes through this latest episode, but it takes him a full four weeks. Finally he reports, “Made first drawings for the work.”

  Now just 360 more to go.

  Gray’s workload was no less daunting. He would have to write nothing short of an encyclopedia on anatomy in less than a year and a half. Under the circumstances, I would almost expect more quarrels and creative differences to have surfaced between the two men. But such did not seem to be the case. From the outset, author and artist shared a strong vision of the book they wanted to create. As historian Ruth Richardson observes in her introduction to the thirty-ninth British edition of Gray’s Anatomy, “Neither was interested in producing a pretty book, or an expensive one. Their purpose was to supply an affordable, accurate teaching aid for students like their own.”

  As both men dealt with students on a daily basis and had recently been students themselves, they knew that small innovations would make a big impact. Unlike Quain’s Elements of Anatomy, which came in a three-volume set, for instance, this book would contain in a single volume everything a student needed to know about the human body. Further, bucking the trend of pocket-sized texts, some as small as 4 by 6 inches (10 by 17 centimeters), Gray, Carter, and their publisher, John Parker & Son, also planned a larger than usual book, with a no-squinting-necessary text size and illustrations that could breathe. Even at this size, 6 by 9½ inches (15 by 24 centimeters), it would still be light and easily totable. Parker & Son would also be happy, as this was a cost-effective size to print. The bottom line was, the book was shrewdly designed from the get-go to sell.

  I cannot help bringing up a small irony here. The very phrase that H. V. Carter had used as an epithet to describe Gray also serves as a perfect characterization for the book the two had in mind: it would be altogether practical. What’s more, practicality would be a guiding principle throughout the project’s eighteen-month duration. Between author and artist, there would be no wasted effort. Performing dissections together, for instance, would save time on many fronts, including helping them come to a speedy agreement on the fine points of each illustration—what stage of a dissection should be drawn, what perspective to use, and so on. As seasoned anatomists, too, they certainly knew how to make the most of their most precious resource, cadavers. Between dissections done for classes and those for the book, no material would go to waste. I expect the same could be said when it came to the manuscript. Gray undoubtedly drew upon his three-year back catalog of lecture notes as a basis for his text and, alternatively, used any freshly written text as a basis for new lectures. This, I believe, helps explain the distinctive tone of Gray’s prose. You can open the book to almost any paragraph and find the clear, unrushed voice of an experienced instructor speaking directly to a rapt classroom.

  Carter was able to do double duty as well, using dissections he had performed as demonstrator or for the Anatomy Museum as subjects to be drawn for the book. At first, he drew on paper, but about six months into the project, he made a radical change. He began drawing directly onto the wood blocks that would ultimately be used for the book’s engravings. Whether at the publisher’s behest or, as I suspect, on his own initiative, this would end up saving a huge amount of time by bypassing the need to have someone else transfer the drawings from paper to wood. Still, it was akin to switching to a whole new medium, and Carter found the transition bumpy. “Pretty assiduous at Kinnerton Street,” he notes after one of many long days spent in the lab. “Drawing from nature and on wood. Result of latter, so-so. Require practice, improving.” Strikingly, he does not sound frustrated or discouraged, which is right in character, since Carter was always happiest when engaged in learning something new. And one need look no farther than the finished book to see how perfectly he mastered the technique.

  I should mention one last major time-saving device Carter employed, one that, upon first learning of it, came as a surprise to me: he copied some of the illustrations from other anatomy books. This fact, omitted from the later American editions of Gray’s Anatomy, was acknowledged right up front in the original English edition at the beginning of a seven-page list of illustrations (also left out of later editions, if only to save space). The number of copied illustrations was small, 77 of the 363 total, and it is easy to understand Gray and Carter’s rationale: If another arti
st has perfectly captured a dissection, why not use what’s ready-made? You would save not just time but a cadaver, which, in the spirit of the endeavor, seems eminently practical. But what merited borrowing?

  As it turns out, Carter pulled not from one or two but from nineteen different sources, including his beloved Quain’s. This discovery invokes the wonderful image of the two men raiding the St. George’s Lending Library and of Henry Gray’s home office being carpeted with dozens of anatomy books laid open to possible candidates.

  I TAKE A seat as Ms. Wheat studies my list of the nineteen artist-anatomists. It literally goes from A to Z—Arnold, first name Friedrich, to Zinn, first name Johann—and comprises a who’s who of leading figures of the nineteenth century, not only English anatomists but German, Italian, French, Scottish, and Dutch as well. Most of these luminaries have since faded into obscurity, however, and copies of their works are now exceedingly rare. Which is the reason for my visit.

  Ms. Wheat hands back the list and asks just one question: Where would I like to begin?

  “With Arnold,” I reply without hesitation, and not simply because he is alphabetically first on the list. A third of Carter’s copied illustrations come from this single source. Friedrich Arnold (1803-90) was a longtime professor of anatomy at the University of Heidelberg, and he specialized in the microanatomy of the nervous system. He was the author of some sixteen books, most of which he also illustrated, one of which is now being delivered to me personally.

  Ms. Wheat places a foam lectern in front of me, followed by Icones Nervorum Capitis (1834), Arnold’s first illustrated work, a monograph on the cranial nerves. It takes just a preliminary fanning of the pages to understand why Carter would wish to copy from it. Arnold’s artwork is seriously beautiful, as is the book as a whole. The pages are oversized and the lithography of the highest quality.