The Anatomist: A True Story of Gray's Anatomy (11 page)

As I read of his fears, I felt great sympathy; moreover, I found myself identifying with this tortured Christian English Victorian diarist, a man both 25 years younger and 155 years older than I am right now. The question he was agonizing over, boiled down to its essence, was the same question that had plagued me as a young man: should I come out? In his case, should I come out as a Dissenter? Pausing over these two pages, I wished for him what I myself had desperately wanted at age twenty: for that perfect, knowing someone to show up and say that perfect, knowing thing—the answer to everything. Absent that, I was glad that, like me, Carter had a place to pour out his soul.

Compounding his isolation, Carter was unable to speak of his struggle with friends such as Henry Gray. He feared jeopardizing his standing at the hospital. (Henry Gray, as the son of an employee of the royal family, was presumably a loyal son of the Church of England.) Nor did he confide to John Sawyer and his family. (Though Dr. Sawyer was not religious, his wife and daughters were Dissenters, though, as Carter implies, of a diametrically opposed denomination.) And to his fellow parishioners, he did not dare voice his doubts, lest he be labeled a skeptic.

While it doesn’t lessen the poignancy of H. V. Carter’s situation, with hindsight one can see that his intensely private struggle was a reflection of larger conflicts arising during the mid-Victorian era. Increasingly, religious belief was being challenged by the new science, Charles Darwin’s emerging theory of evolution particularly. At the same time, however, the faithful were in some cases turning
to
science—and to scientists—searching for ways to reconcile science and religion. H. V. Carter was a particularly avid reader of the work of William Paley (1743—1805), for instance. Paley, an English scientist and theologian, claimed that proof of the existence of God could be found in our physical bodies.

Though Paley wrote chiefly in the late eighteenth century, his words resonated well into the nineteenth and, in fact, can still be heard today in the “antievolution” movement advocating intelligent design. With Paley, it is important to bear in mind, however, that he was writing before Charles Darwin was even born, not in reaction to Darwin’s theories.

In his most popular and influential work,
Natural Theology; or, Evidences of the Existence and Attributes of the Deity,
Paley introduced his now-famous metaphor of the watchmaker: if you had never in your life seen a watch, then found one lying on the ground and examined it, you would come to the inevitable conclusion, Paley writes, “that the watch must have had a maker—that there must have existed, at some time and some place or other, an artificer or artificers who formed it.” One must come to the same conclusion, he argues, regarding far more complex structures—plants, animals, and human beings. In short, only an “intelligent Designer” could have created them, just as only an “intelligent watchmaker” can make a watch. “That Designer must have been a person. That person is God.”

While nature offers multiple proofs for the existence of God, Paley singles out one as definitive: “For my part, I take my stand in human anatomy.” In making his case, he moves beyond the biblical teaching that humans are made in God’s image. Paley presents what amounts to an anatomical travelogue of faith, pointing out those parts of the human body so perfect in design and purpose that God’s hand is obvious: “The pivot upon which the head turns, the ligament within the socket of the hip-joint, the pulley or trochlear muscles of the eye,…the knitting of the intestines to the mesentery,” and on and on, as if he somehow sees each piece of evidence right through the skin.

Part sermon, part anatomy lecture, this passage sounds as if it were written expressly for Carter, who, of course, knew these places well. It also contains the key to understanding a puzzling diary entry, which, in turn, unlocks a secret to understanding the young H.V. The entry comes in the first pages of Carter’s first diary. On Sunday, January 7, 1849, the seventeen-year-old reports going to chapel twice and spending time reading Paley’s
Natural Theology.
On the left half of the page, he jots, “Acquired a
new idea
from it,” underscoring his excitement. And just to the right, he places a quote I recognize from Ecclesiastes, the most dour book of the Old Testament: “‘With much
wisdom
is much grief and he that increaseth his knowledge, increaseth troubles.’” The one thought is shoved to the left side, the other to the right—
For
and
Against,
I realized. But why? Why the opposing thoughts?

Like Paley, he could see the divine in the body. But here’s the rub, as Carter might say. Even at this early date, he knew too much—too much about human anatomy—not to also see the imperfections, the
flaws
in the body’s design (for instance, the single passageway that both food and air share, which can result in choking). Hence, for H. V. Carter, the conflict between faith and knowledge was embodied in the body itself. The Christian within him could see what Paley could see. But the anatomist knew better.

Seven

A
FTER THREE WEEKS OF CLASS, I AM SERVING AS A DEMONSTRATOR
of anatomy.

My duties are quite different from Henry Gray’s when he was demonstrator of anatomy (one of his many roles at St. George’s). He would stand in front of the class, behind a cadaver, showing students the parts of the body being described by the lecturer. The anatomy I am demonstrating, by contrast, is my own.

With my shirt off, I have assumed what is called the anatomical position: standing upright with feet together, hands at the side, palms forward, with eyes directed toward the horizon, or, in this case, toward the Golden Gate Bridge, visible due north out the lab windows. The anatomical position, used in all medical disciplines, is the standard body position for referring to the location of any structure. In this pose, the subject becomes an object.

Following Dr. Topp’s directive, the eight PT students grouped around me have to find the “bony landmarks” of the surface anatomy of the upper body, all fifty of them. Some are clearly visible, such as the shaft of the clavicle or the spine of the scapula (the collarbone and the sharp edge of the shoulder blade, respectively), but most need to be palpated. The gloves come off, the better to feel what is just under my skin. An easy one to find right away, on me as well as on most people, is the C7 spinous process. Translation: the bump at the seventh cervical vertebra. To most of us, this is the knobbiest knob you feel when massaging the back of the neck. To a physical therapist, it is the starting point for locating any of a patient’s thirty-two other vertebrae. Counting upward, there’s C6 to C1, while downward from C7, the remainder are grouped by region, with twelve thoracic, five lumbar, five sacral, and, finally, at the tailbone, the three to four coccygeal vertebrae.

Just as landmarks are handy when one is driving—
Take the second right after the movie theater,
for instance, or,
If you pass Millie’s Diner, you’ve gone too far
—the landscape of the human body is more readily navigable for its markers. One of the most clinically important is the sternal angle, a slight ridge of bone near the top center of the sternum, or breastbone. If you’ve ever pointed at yourself while asking someone, “Are you talking to me?” you have probably pointed right at it. Its exact spot is most easily found by first slipping your finger into the groove at the very bottom of the throat, which is the very top of the sternum. This is the jugular notch, and the tip of the finger seems to fit perfectly in it. Now slide your finger down the sternum about 1½ to 2 inches (4 to 5 centimeters) to the first tiny bump or ridge. You have found the sternal angle. Just behind it, along the same horizontal plane, the arch of the aorta begins its arching, the trachea splits into the bronchi, and, deeper still, the thoracic vertebrae 4 and 5 are situated.

A landmark to other clinical landmarks, the sternal angle is indispensable for correctly identifying the ribs, which are counted top down, with twelve on each side. The first rib, embedded under the clavicle, cannot be palpated. The second, however, lies to the right and left of the sternal angle, though the bump can be subtle. From here, moving downward and sideways, you can count ribs 3 through 10, all of which connect to the sternum via a small portion of cartilage. The last two ribs on each side are unique in that they end roughly halfway around the torso. These are the “floating ribs,” and their tips can be felt just above the waistline.

Now, repeat eight times, without squirming, and you’ll have an idea of what my morning has been like. As it turns out, my rib cage is good for counting because I don’t have a lot of body fat. My arteries are easy to palpate, veins easy to see. The students tell me I have a very well defined bicipital groove and impressive biceps, too. But compliments gradually give way to a sharper truth: my body serves as a primer on being middle-aged.

Both my scapulas wing a bit too prominently, a possible sign of weakening serratus anterior muscles. My collarbones are uneven, probably from shouldering my gym bag on my left side for the past twenty-odd years. And my right shoulder joint makes a clicking sound as it rotates, apparently an early sign of arthritis. Once this is discovered, the entire class descends and I become the morning’s star attraction:
Come, see the man who clicks!
I am glad we are not going to move on to the lower limbs today—the hip joints, knees, and arches—where I have more serious problems, thanks to years of running and working out. Instead, we shift from the living body back to the dead for the remainder of lab.

We have to perform a blunt dissection, meaning that the focus is on the destination, not the getting-there. All that’s required is a large scalpel blade, a deep breath, and an extra-deep cut. It takes half a minute, maybe less. For this particular dissection, you just slice straight across the crease at the crook of the arm (
you
being
me,
in this case, with Kristen, Sam, Kelly, and Cheyenne looking on), then make small perpendicular incisions at either end, peel back the flesh, and—

“Wow.”

The five of us are a choral group of exclamation, though we know only one song. We sing it again:
Wow.

Peeking through the crevice of mud-colored flesh is a glint of ivory, our truck driver’s elbow joint, our destination. I finger away the fascia till the joint capsule is fully exposed, then snip away its papery protective membrane.

Even in a long-dead body, a joint remains a thing of beauty. It is smooth and shiny and still gleams with synovial fluid, the clear substance that keeps the joint lubricated or, if you will, greased. In
Gray’s Anatomy,
Henry Gray describes synovial fluid as “glairy, like the white of an egg,” and “having a slightly saline taste,” a phrase that begs a question that is perhaps best left unanswered: did he actually put a dab on his tongue?

I take a step back as my lab mates take turns digging a little farther, exposing the three long bones that meet, or “articulate,” here at the elbow: the humerus, the single bone of the upper arm; and the radius and ulna, the two bones of the forearm. Like all joints in the skeletal system, the elbow joint is not a part per se but a
place
where parts come together. However, unlike the simple hinge of a knuckle joint, for example, the elbow joint is tripartite, a three-way intersection of bone. Here, the radius and ulna articulate with each other and, separately, sometimes simultaneously, with the humerus.

A joint is usually powered by muscle and nerves. This one is powered by Kelly. She pronates the cadaver’s arm, and we are all floored.

Pronating is rotating the forearm so that a palm facing upward turns downward. A person does this countless times in a day without a moment’s thought, as when you turn your hand over to look at your wristwatch. Yet, seeing the inner workings of this simple act is nothing short of profound. Kelly turns the arm again. In a single, perfect movement, the head of the radius spins in place on the humerus while the shaft rolls over the ulna. They return just as gracefully to their side-by-side position during supination, the reverse action, which again turns the palm upward. That a bit of life seems to linger in this dead body is surprisingly unghoulish.

We all take a turn, rotating the arm as well as flexing it in a modified biceps curl. Just making the movement occur, though, is not enough. Each of us is compelled to place a gloved finger directly in the elbow joint as the bones twirl and glide, to feel what can only be felt from the inside: movement at its source.

Dr. Topp, overhearing our excitement, comes to take a look. “Even after all these years,” she leans in to me and says, “I still find that really cool, too.”

I look around and see jaws dropping at every table. Celeste and her group have exposed the shoulder joint, a ball-and-socket that has pulled them into its rotation. One table down, it is circumduction of the wrist. Two over, it is pronation of the opposite forearm, the elbow dance in reverse. Students stroll around the room, table to table, watching, making, and feeling the movements. Everyone here, the living and the dead alike, has become a demonstrator of anatomy.

IF NOT IN
the classroom demonstrating, he might be found in the lab dissecting. And if not in the lab, then at the hospital, whether in surgery or in the morgue or in the Dead House, or maybe in a meeting, being by now a member of the board of governors of St. George’s, not to mention the London Pathological Society and the Royal Medical Society and the Hunterian Society. And with the few spare minutes left in a day, in early October 1852, Henry Gray could most likely be found in his office at home. But do not disturb him. He is trying to complete his treatise on the spleen, a project he has been working on for more than two years now, and it is due in less than two weeks.

This would be Gray’s submission for the Astley Cooper Prize, a prestigious award based on a dead man’s unusual posthumous request. As mandated in the will of Sir Astley Cooper (1768—1841), every third year a judging panel would accept manuscripts of original research on a predetermined anatomical part, pulled from a list he had drafted. The spleen was the current topic of inquiry. The not insignificant cash award to this triennial prize, paid from a sizable endowment, was £300. The winner would be announced the following July.

Cooper, a highly regarded English anatomist, surgeon, and professor, had died when Henry Gray and Henry Vandyke Carter were just boys. But he was responsible, in a sense, for bringing them together. Had it not been for Sir Astley’s prize, after all, Gray might not have found himself in need of an artist, back in June 1850; Carter might not have found himself offering his services; and, ultimately, the two Henrys might never have become friends.

There is no better gauge of a friendship, I believe, than the ability to do nothing together, and, as Carter’s diary testifies, the two had little trouble in that department. They would often while away quiet afternoons together, and one day Gray even coaxed Carter into doing something completely out of character: the two men stepped out of the hospital doors and just kept walking. Once they got to Chelsea, they took a leisurely boat ride on the Thames, eating up a whole half day. Carter, in other words, had played hooky! He normally fought against “idleness” and berated himself for each misspent minute, yet he never portrayed being idle with Gray as wasted time. Gray felt likewise, no doubt; in H. V. Carter, he had met a kindred spirit.

Despite the differences in age, religion, and family background, these two shared a keen interest in medicine and science, of course, but also a passion, verging on the macabre, for dissecting. For instance, even after Gray completed his one-year stint as postmortem examiner (1848—49), he continued on in an unofficial capacity. Quite often, Carter attended these autopsies as an observer, and at least once that I can verify, he assisted Gray in a PM exam. For both men, a postmortem was a dissection with a puzzle built in:
What went wrong here?
Sometimes, in addition, the examination yielded an unexpected anatomical treasure, such as a heart with four rather than three cusps to the aortic valve, an astonishing anomaly.