The Anatomist: A True Story of Gray's Anatomy

by Bill Hayes

  Before I started studying anatomy, I certainly had no idea that we have under our skin a kind of second skin. And in truth, over the course of the courses, I have really viewed fascia only as the tissue one has to cut through to get to the “good stuff.” Henry Gray was never so dismissive. In fact, I now think of him as a passionate pro-fascia-ist. He considered fascia no less important than muscles in the overall composition of the body and gave the two equal billing in the third chapter of Gray’s Anatomy. Aware that this was an unconventional way to present the material, he felt the need to explain himself. The muscles and the fasciae are described conjointly, Gray writes in his introduction, because of the “close connexion that exists” between them. With that point made, he adds an observation of another sort. “It is rare for the student of anatomy in this country to have the opportunity of dissecting the fascia separately.” When one presented itself to me, therefore, I jumped at the chance.

  And whom should I find but Professor Gray himself? There on Chapter One of the lab manual was his classic description of fascia, almost like an epigraph introducing the dissection I had to complete. The wording was all quite technical, really—“The fasciae are fibroareolar or aponeurotic laminae of variable thickness and strength found in all regions of the body,” and so on—but I could not help noticing that one tiny clause had been lost in transcription. In the original, Gray notes that fascia is Latin for “bandage,” a simple fact that conveys a helpful image. Like a bandage, fascia wraps around, covers, protects, and binds. There is no better place to see this bandaging effect than in the thigh, where the body’s largest and longest muscles are found.

  As a time-saver, deskinning of the upper thigh was supposed to have been done in advance by the teaching assistants, but they had obviously run out of time before getting to our table. I don’t mind. I look upon it as a chance to pay extra-close attention to the layer of “superficial fascia” that undercoats the skin. In appearance, superficial fascia is as different from the second type of fascia, “deep fascia,” as apples are to oranges; in fact, it brings to mind oranges, fittingly enough. If you could invert your skin, à la an orange rind turned inside out, you would find the entire surface lined with a similar soft, spongy whitish material. That is superficial fascia. It makes for a great insulator and acts as a support structure for sweat glands and superficial nerves and blood vessels. By contrast, deep fascia is more fibrous and therefore tougher than superficial fascia, and, as its name indicates, it is located deeper within the body. In the thigh, deep fascia is called fascia lata, so named, Gray explains, for its “great extent” (lata meaning “broad”), and, sure enough, I find this taut, opaque tissue wrapped around the full extent of the thigh like a big Ace bandage. It not only binds the thirteen meaty muscles within but also intensifies the force they generate.

  To cut it apart, I choose scissors. With the tip, I puncture a hole in the fascia lata at the lap line, then scissor downward to the middle of the kneecap. It is as easy as cutting fabric. I make crosscuts at the very top and very bottom and peel the long double doorways back.

  I have just cut my way into what’s called the anterior compartment of the thigh, the largest of three fascia-walled sections surrounding the femur bone. Each compartment is literally a discrete room housing a set of muscles related to one another by function. For instance, the thigh’s main extensor muscles, which help extend the leg, are all bundled together in the anterior compartment. My next task is to unbundle them.

  There is no better tool for this than the fingers. (Gloved fingers, mind you.) I press into the mass of undifferentiated fibers, feeling for seams. Deep fascia binds these individual muscles together as well, but it’s of a different consistency here—more like a sticky fluid, viscous and clear—and I easily work the muscles apart. The first to pull free from the pack is the sartorius, the longest muscle in the body, which extends from the hipbone to the inside of the knee. By running it between my thumb and fingers, up and down, up and down, I am able to clean its whole length. But in the pulling apart, I have broken the fascial bonds that give the muscle stability and support. The sartorius now drapes across the thigh like a sadly sagging sash.

  Unbeknownst to most people, the human body has several biceps (a single muscle with two parts, or heads); the biceps that bulges when someone says “Make a muscle” is simply the most famous. There are two triceps muscles, triple-headers. But there is only one quadriceps, the quadriceps femoris (or, as it is commonly known, “the quads”), and it forms the main bulk of the anterior compartment. As I separate and clean each of the four muscles, I find myself dissecting dissection itself. How would I explain this to someone, I start to wonder, the satisfaction that one derives from dissecting?

  The pleasure, I decide, lies in making order of the disorder, in tidying up what looks messy. It is an art well suited for fastidious types such as myself. “Make it pretty,” Kim and Dana often instruct, half seriously, but it’s true—that is exactly what one strives to do. When done well, dissection is very pleasing aesthetically.

  With the anterior compartment completed, I move on to my final task, the dissection of the “femoral triangle” in the upper inner thigh. If you make a triangle of your forefingers and thumbs, you have approximated the size of the femoral triangle. It is bordered by two distinct muscles and a ligament (the sartorius, adductor longus, and inguinal, respectively). I remove the skin and fascia covering it, only to find a thick chunk of yellow fat. Such a sight would have made me recoil not long before. But I have gained a healthy respect for fat. In modest amounts, it serves a vital purpose, providing insulation as well as protection—padding. In fact, there is an unwritten anatomical rule (clearly written in leaner times) that if you find fat, you’ll find structures in need of protecting. I put down my scalpel and, again, use my fingers, operating purely by touch. Sure enough, deep within this chunk, I feel a thick vessel. That’s got to be the femoral artery. I do not need to glance at the lab guide; I know it. The femoral, used for coronary angioplasties, runs a nearly straight shot up to the heart. And now I’m going to find—yes, here we go—the femoral vein and nerve. Everything is in its proper place.

  That the body is structured in such a consistent, organized way is another reason I find dissecting supremely satisfying, a view that Henry Gray surely shared. In fact, perhaps I misstated it earlier. Dissecting really has nothing to do with making things orderly. The order is already all there, just under the surface. The anatomist only has to uncover it.

  HENRY GRAY IS in a box somewhere, I keep telling myself. Somewhere he survives in a box of letters, personal papers, manuscript drafts, page proofs (something), stashed away in a basement, a mislabeled carton, a forgotten storeroom, a locked drawer (someplace), just waiting to be discovered. But the box eludes me still. My many inquiries to libraries, universities, and medical societies have resulted only in the most politely worded series of Nos. Recently, however, two separate archivists I’d contacted added an intriguing footnote. Both mentioned another person who had made similar queries about Gray’s papers. Maybe he found something? Unfortunately, the inquiries had been made more than a decade earlier. Fortunately archivists specialize in saving such items as old correspondence; soon, I have a name and a London address. I dash off a letter.

  Just four days later, an e-mail arrives from Mr. Keith E. Nicol. Though I’d purposely kept my letter brief, simply introducing myself and expressing my sincere interest in Henry Gray, apparently this is all Mr. Nicol needed to know. “I look forward to assisting you with your research, as I have quite a lot of information on Gray and his life and career in medicine,” he writes, suggesting that I begin by compiling a list of questions. “I will do my best to answer them.” It’s as though he had been waiting to hear from me all this time, and now he is eager to get started.

  I promise to get back to him with a list of questions, but first, just one: Where had his interest in Gray originated?

  He was working at a London teaching hospital in 1990,
he replies, and had begun assisting a fellow staff member who was contemplating writing a biography of Henry Gray. The project didn’t last long for either man. By year’s end, Keith had been “made redundant” from his job, and soon after, the writer decided there was just not enough material for a book. Regardless, Keith had become hooked. Trying to piece together the anatomist’s life was a puzzle he could not set aside. And though he had no writerly aspirations himself, he took over the Gray research completely. Slowly, painstakingly, he accumulated a tidy collection of facts and details, most of which he discovered through old-fashioned detective work, hunting through municipal records offices and local libraries and archives, including those of St. George’s Hospital.

  While nourishing his larger fascination with English history, the research also offered Keith a diversion during some very difficult times. In the midnineties, his wife was diagnosed with breast cancer and, after an eight-year illness, died in the spring of 2003. The year before Sue’s death, however, he had been able to bring his decade-long pursuit of Henry Gray to a satisfying close. He had created a year-by-year breakdown of the anatomist’s life, a document that documented Keith’s research.

  “I shall post a copy of the chronology to you tomorrow,” he promises.

  Till then, Keith had a single question for me, one that brings a smile to my face: “Are you aware of the link between Henry Gray and Henry Vandyke Carter?”

  SIX WEEKS AFTER his mother’s death and eight weeks before the anatomy book was due at the publisher’s, H. V. Carter hit a wall. “I have fallen into a languid state, with occasional fits of despondency and ever-active and vagarious thoughts, ’specially of the future,” he reports to his diary, May 31, 1857. As if making a diagnosis, he adds, “This state is probably somewhat morbid—the result of a single constant, solitary occupation—this drawing on paper and wood.”

  That he would blame the book is understandable. For sixteen months now, he and Henry Gray had been toiling away at what, at times, must have seemed like an endless project. Simple math says that Carter had to complete two drawings every three days over the eighteen-month period, though, clearly owing to his talent, there is not a single image in the completed book that looks rushed. Tellingly, Carter writes of drawing as if it were his sole, all-consuming job, when, in fact, he had also been serving as demonstrator of anatomy throughout this period and, since the previous June, as demonstrator of histology, not to mention his tutoring for several hours each day. Calling drawing a solitary occupation, though, was no exaggeration. Save for Saturday afternoons, which he spent with Gray, Carter worked by himself at home, and, he acknowledged, the quiet sometimes got to him. I can well imagine that on Sunday, his one day off, he rejoiced in the fellowship, albeit fleeting, he felt at church.

  Gray was just as busy as his collaborator, if not more. He had to produce, on average, ten pages of text every week, on top of holding three separate jobs—lecturer on anatomy, curator of the Anatomy Museum, and surgeon to the St. George’s and St. James’s Dispensary—as well as fulfilling his duties as a member of the Pathological Society Council, the Royal Medical and Chirurgical Society, and the Royal Society.

  One glaring difference between the two Henrys, however, was financial. While Gray was making a handsome living at the hospital, H. V. Carter, by contrast, was not being paid for either of his St. George’s jobs. The histology position came with no salary—he had taken it as a favor to Gray—and, shockingly, as demonstrator of anatomy, he had not been paid a pound in eight months (funding had dried up after his mentor Dr. Hewett retired). The disparity in income between them was even more pronounced in their respective contracts for the book. While Gray would be paid £150 for every thousand copies sold (an arrangement that would ultimately benefit four generations of Grays), Carter, who had negotiated his own contract with the publisher, would receive no royalties, only a onetime fee of £150. Why should he have accepted such an inferior arrangement? To him, it wasn’t—£150 was three times larger than the salary for a demonstrator—but finally, his own naïveté also played a role.

  As for why Carter soldiered on at St. George’s, this was partly out of loyalty to Gray, I believe, and partly because he was well suited to soldiering. He also felt, at least initially, that his unpaid work might eventually pay off in his forming the right connections and, should Providence allow, a plum job. But now, he was clearly having second thoughts about staying on at St. George’s. A vacancy for curator of the Pathology Museum had opened up in March—a position equivalent to Gray’s at the Anatomy Museum—but, two months later, Carter still had not decided if he would even apply for it.

  “I’m constantly imagining myself in another position—as surgeon in a small country village, or the like,” he confides to his diary. However, faced with endless drawing, he had begun to fear that “[I’m] losing much of the little practical professional experience I had.” This was a legitimate concern. Though he had recently earned his final certification to practice medicine, having passed the M.D. examinations in late November 1856, Carter had treated no patients other than his mother and done virtually no hands-on doctoring since he’d filled in for John Sawyer two and a half years earlier. Adding to his anxiety was the reality that, at age twenty-six, he was off to a late start in establishing a career.

  “All my fellow students, and most since my time, have left the School and are settled in life,” he observes on another date. “Whenever I hear of their advancement, or meet them, [these] active men, there is a kind of stunning sensation or pang in one’s breast—and the same kind of feeling on seeing the younger students emerge into grown manly fellows.” Indeed, as Carter notes, the very pupils he had been teaching would be his competitors for the same jobs and, because of their youth, perhaps have an edge. The thought is almost too depressing for him to contemplate. What never occurs to him, ironically, and never would, is that the bane of his current existence—drawing—would end up making his name. For the moment, all he can think about is bringing this “quiet mechanical occupation” to a close and putting the anatomy book behind him.

  And what about the author? During the same month, as Carter wallowed in his “languid state,” was Henry Gray over at 8 Wilton Street burning the midnight oil, finishing the last chapters of the book? Was the undertaking taking its toll on Gray as well?

  Maybe.

  Upon receiving Keith Nicol’s chronology, I turn at once to the year 1857, hoping for a revelation. There is none. Alas, Keith had not discovered a cache of Gray’s papers, a diary, or anything of the kind. In fact, Keith later tells me, he had found almost nothing about Gray’s personality or personal life during his research. Keith did, however, track down a small collection of letters written to Henry Gray (now in the possession of a distant relative). In these, a curious fact emerged. At the end of May 1857, Gray took a six-month leave of absence from St. George’s, during which he served as personal physician to George Granville Sutherland-Leveson-Gower, the second Duke of Sutherland, a seventy-one-year-old nobleman whose London home was a quick brougham ride away. The correspondence gives no hint as to why Gray would take this job, but to me, there’s an obvious explanation. It was not for money or prestige or the chance to rub elbows with royalty—granted, all nice inducements. No, to echo the two Henrys’ guiding principle, it was for practicality’s sake. With the Duke of Sutherland, Gray would have just one patient (the duke lived four more years, so I suspect his demands on the doctor were not extravagant), and this arrangement would give Gray the one thing he needed most: extra time. Freed of his usual responsibilities, he could bring his manuscript, at long last, to its end.

  I HAD NEVER heard a single unflattering word said of Henry Gray. Then I spoke with Charlie Ordahl.

  “Over the past couple centuries, anatomists like Gray have been like the monks of the Catholic church, re-creating the same illuminated manuscript,” he tells me after lab one day. Dr. Ordahl—“Charlie, please”—is one of the eight anatomy instructors. “It’s the whole scrib
e-type tradition,” he continues. “Very honorable. But that mentality is what makes anatomy as a science such a failure. Nothing changes, decade after decade. Textbooks are the same. It’s taught in the same way—with cadavers, all on-the-table, same position. The same memorizing in the same order of all these parts you’re never going to see again.”

  Little did I expect that the mere sight of my copy of Gray’s Anatomy would provoke such a prompt mounting of a soapbox. But Charlie can stand on the book itself if he desires. I am quite enjoying his diatribe. “So, why do you think that is?” I ask, urging him on. “Why has nothing changed?”

  “Well, it’s partly the power of a paradigm,” he resumes. “Anatomy is like gravity, to most scientists. You don’t question it.” In addition, he notes, after William Harvey discovered the circulatory system in the early 1600s, there wasn’t really much new to discover in the body. It had all been found. “Anatomy became encrusted; it lacked a raison d’être.”

  Charlie may sound like a newcomer, one of the new breed of computer-simulation-loving anatomy instructors, but he is actually an old-timer, a white-haired bear nearing retirement age. “So if the field is rusted over,” I ask, “what is the point of teaching it this way?” I look around the lab, gesture at one of the cadavers. “Is it just tradition?”

  “Sure, that’s a big part of it. But the real deal is, you can’t do medicine without it. You have to have that basic understanding of anatomy. Of course, I think you can make it a lot more streamlined. Teach it in a much more focused way. Doctors don’t remember any of this stuff. Ninety percent of what we throw at them doesn’t stick.”