The Anatomist: A True Story of Gray's Anatomy (19 page)

AS THIS IS
my third first day in just six months, one would think the scene around me would be utterly familiar. Well, yes and no. The freshly polished linoleum gleams. The blackboards have been sponged clean. The lab guides at each station are centered and new. But what transforms the lab into something completely different is the suffocating crowd. It is two minutes past the hour, and 143 first-year med students are scrambling to find their assigned tables among the cadavers, squeezed in three to a row, eight rows long, as eight instructors direct traffic.

Luckily, I arrived just before the big crush of students and easily found my table, number 24, back in the left north corner. This is a great spot, as it’s right next to a bank of windows with a spectacular view of the Golden Gate Bridge. For the moment, there are just two of us here, me and a fresh cadaver—female, aged eighty-eight. Then, out of the sea of periwinkle and green scrubs, Dr. Topp appears with someone in tow. “Bill, this is Kolja; Kolja, Bill; you’ll be lab partners, okay? Great!” she says, and then, as though taken by a rogue wave, she is gone.

“Kole-ya, is it?” I say, pronouncing it just as Kim had.

He nods and, as if anticipating the question everyone asks, explains that, yes, his parents named him after Kolja Krasotkin, the young hero in Dostoyevsky’s
The Brothers Karamazov,
but no, he is not Russian. He adds that he lives in Berkeley and just finished a Ph.D. in chemistry at U.C. Berkeley.

Kolja looks ten years late to class. He is about thirty years old, I would guess, and wears sandals and an oversized T-shirt instead of the traditional sneakers and scrubs. His long blond hair is pulled into a loose ponytail. But what is most striking about Kolja is how mellow he seems. In fact, I cannot help asking, “So,
are
you a med student?”

“Oh, yeah,” Kolja replies, “I just decided to head back to school.” He’s still looking for his niche, he adds.

Our four other table mates arrive all at once, and after quick introductions, we huddle around the lab manual. Our first act as a team is to split up. Every table of six is divided into twos, and each pair has a separate assignment for each hour of lab. We are to rotate at the hour and at the end of class come together and review. This tight schedule was born of necessity. Med students have so much to learn, so many subjects to cover in their first two years, that their entire curriculum is accelerated. For this anatomy course, three months of work is squeezed into six weeks. Today alone, they have to complete in three hours the equivalent of three separate labs.

First up for Alex and David is starting the dissection of the thorax, while for Marissa and Erica, it is a task just a few inches below: dissection of the abdomen. Kolja and I have been consigned to studying prosections set up at a long table in the center of the lab. Personally, I would rather dissect, but for someone like Kolja, this is not a bad way to begin. Prosections are like anatomical flash cards—good, fast learning aids. We will be able to examine quickly the anatomy that the remainder of our team is slowly cutting through. But there is a problem at the Island of Prosections. It has been overrun by students.

The sight brings to mind vultures swarming around a half-eaten corpse: the table is encircled by other students with this same assignment, all poking and probing the detached parts. Their bodies form a wall, and Kolja and I and a couple of dozen others are already shut out. No instructors are around, as they are all off helping with dissections.

“I think this is partly personality screening,” Kolja comments as we wait for a spot to open up. “You know, weeding out anyone who’s not an alpha male. A ‘survival of the fittest’ kind of thing—”

“Yeah? So how do you respond in situations like this?” I ask.

“Not well,” Kolja admits, and indeed, he suddenly looks paralyzed.

With that, my inner alpha male ascends. “Okay, people,” I say in a raised voice, “can we get in here, please? Please?” I tap someone on the shoulder—“Hey, can you scoot over a little?”—and she obliges. Kolja and I settle in. “Okay, let’s get started.”

Lying before us is not only a selection of preserved specimens—hearts, lungs, and rib cages—but also a fresh cadaver that Dana and Kim had dissected earlier. Its entire chest cavity has been reassembled so we can go through it part by part. It reminds me of a teaching tool popular during the seventeenth century, “Anatomical Venuses,” as they were called—life-sized human models made of wax, with removable parts—except that this Venus has a penis.

Going from the outside in, I first show Kolja the two visible layers of skin, the epidermis and dermis, as well as the major chest muscles, pectoralis major and minor, parts that I had learned so well under Kim’s guidance. Next, I remove the entire rib cage so we can examine the “intercostals,” the space between the ribs. The three thin layers of intercostal muscles—external, internal, and innermost—are clearly distinguishable, thanks to Dana and Kim’s expertise. What they have done is akin to exposing the different layers of a Triscuit, showing the various weaves of wheat. “See how the muscle fibers of each go in a different direction?” I point out.

“Cool,” Kolja responds each time I introduce a new anatomical part.

Moving on, I show Kolja the internal thoracic artery and vein—“They don’t run parallel to the ribs, it’s important to remember, but lateral to the sternum”—and prod him to finger three portions of the parietal pleura (costal, diaphragmatic, and mediastinal), to help him remember how each is different. In this dissected cadaver, with rib cage, lungs and heart set to the side, it is easy to find the phrenic nerve, lying like a loose guitar string from the neck down to the diaphragm. “You can’t breathe without this thing,” I tell Kolja, then share the one mnemonic I had learned from Dana:
C
-3, 4,
and
5
keep the diaphragm alive.
“That’ll be on a test, I can almost guarantee.”

As we continue, a young man across the table interrupts: “Hey, can I ask you a question?”

“Me? Sure,” I respond, “but I’m not a TA or a professor—”

“Well, are you knowledgeable?”

I don’t hesitate. “Yes.”

“What’s this?” He points to a prominent vessel in the cadaver’s neck.

“Well, first, tell me what you think it is,” I say.

“The superior vena cava?”

Everyone else at the table is listening in by this point.

“No,” I answer, “the superior vena cava heads directly into the heart. The one you’re pointing to—see how it goes under the clavicle?—that’s the subclavian vein.”

“Oh, of course, the subclavian! And it changes names, right? Into the, what is it, the ‘axillary’ vein?—”

“Right, very good, it changes
from
the axillary
into
the subclavian once it hits the armpit, right at the level of the first rib.” This guy is not just a good guesser, I’ve figured out. Like everyone here, he has taken basic anatomy before, but he also obviously came to lab super-prepared. Still, there is a big difference between book smarts and body smarts, and this particular vein is very confusing. “Okay now,” I continue, “the subclavian changes names a third time, right? Do you know at what point?”

“No idea.”

“Right here”—I point to the spot—“where it joins the internal jugular and becomes the brachiocephalic, which feeds right into the, the…?”

“Superior vena cava!”

“Perfect,” I say, only now realizing what is going on here: I am actually teaching anatomy to these students (med students, no less), something I would never have imagined myself doing six months ago.

At 2:30, Kolja and I return to table 24, where we find Dana coaching David and Alex in the final phase of removing our cadaver’s lungs. One moment the organs are inside the body, and the next, boom, boom, David and Alex are each cradling one, looking like the proud papas of lumpy gray twins. I congratulate the pair.

The same scene is playing out at tables all around us, and by now, the energy in the room is through the roof. It is hot and sweaty, even by the window, and as I take Erica’s spot at the cadaver, I find that we are standing almost butt to butt with students at the table behind ours. If this were a reality show, it would be called
Extreme Anatomy
or
Speed Dissecting,
and most viewers would find it appalling. But I would not want to be anywhere else but right here. These med students are so quick and keen and hungry to learn. Even Kolja is catching up with the pack. He is a fearless dissector, as it turns out. For this second hour of lab, he and I are stationed at the abdomen, and Kolja has already uncovered two difficult-to-find arteries embedded in the dark, oily folds of the mesentery.

Inches away, Erica and Marissa are working feverishly on the thorax, having picked up where David and Alex left off (they are now at the prosection table). At one point, Kolja and I stop to watch as Erica slices through the pericardium and Marissa carefully uproots the heart from its bedding in the chest. Rather than put it aside, Marissa, aware that our cadaver died of heart disease, holds on to the organ, turning it over in her hands, examining every angle. I can tell that she is looking at the heart with the eyes of a future doctor, a healer, trying to see where the organ broke.

This had definitely been a momentous day for her, Marissa tells me later in the afternoon as we are cleaning up. “I’d taken an anatomy class but never done dissection before,” she goes on to explain. “I thought I was going to hate it, but”—she stops and, as if confiding a secret, adds in a whisper—“I loved it. I totally loved it.” Marissa looks out the window for a moment. “It’s funny, I came into school thinking I was going to go into pediatrics, but now I don’t know. I…I think I might like to do cardiology.”

Out in the hall, I chat with other students and repeatedly hear the same refrain: they liked dissecting, they liked it a
lot,
which is something I do not remember ever hearing said with such enthusiasm in the other anatomy classes. But then, of course, these are budding doctors. The
body
—in all its fleshiness, complexity, gruesomeness, and beauty—speaks to them,
sings
to them, in a distinct and powerful way. My favorite remark comes from Rayuna, an Indian woman with the carriage of a ballet dancer, who tells me with infectious delight: “It’s really
crowded
in there,” referring not to the anatomy lab but to the abdominal cavity. “Amazing, just amazing, how everything twists and turns and wraps around.” She pauses, as if picturing a whole body in her mind. “It was so cool to see inside.”

At least one student hadn’t been quite so wowed. Blake, whom I find sitting on the floor slumped against his hall locker, looks totally drained by the experience. After a friendly hello, I ask what had surprised him most about his first day of lab.

“That my cadaver was a woman,” he replies without hesitation.

Of all the things I might have expected him to say, that was nowhere on the list.

“I assumed I’d get a man,” Blake clarifies. “I don’t know why, I just thought I would—so I was really…
surprised
that I got a woman.”

He must have seen the
huh?
still stuck to my face. Blake confides that his grandmother is terminally ill, and he’d dreaded the idea of having to dissect an elderly female cadaver. Then he got one, and, wouldn’t you know it, he discovers that the cause of death was the same lung condition his grandmother is suffering from, COPD, chronic obstructive pulmonary disease. “That was kind of upsetting.”

Blake looks down at his hands for a second. “But then, it was kind of weird,” he says. “I had to dissect the lung, of all things, that was my assignment, and I almost felt bad or guilty because I didn’t freak out. I just, you know, followed the instructions and basically chopped it off and scooped it out with my hands—” He winces at his inelegant phrasing. “I almost wish—”

“You’d had a harder time doing it,” I say.

“Yes.” He falls quiet.

“Well, hey, look at it this way,” I tell him. “It’s your first day of medical school, and you’ve already learned what must be one of the hardest lessons.”

He gives me a skeptical look. “Yeah? What’s that?”

“Keeping your emotions in check so you can do your job.”

Blake manages a half smile and nods.

Twelve

H
.
V. CARTER WAS ONLY TWENTY AND NOT YET A DOCTOR WHEN
he began doctoring his own mother. This went way beyond making pills for her, as he had in the past. He now felt competent and confident enough to help direct her care. During his time home for Christmas break 1851, he gave his mother an extensive physical exam, after which he wrote up his findings and recapped her entire medical history in his diary (on Christmas Eve, of all nights). What had heretofore gone unsaid he now makes clear: his mother, forty-one years old, had breast cancer.

“M.” had discovered a lump fourteen years earlier, Carter writes, but, “suffering no inconvenience,” paid it no mind until seven years later, when the mass began to grow and the pain became chronic. Even so, it would be three more years before M. traveled to London to see a specialist—Henry Gray’s mentor, the famed Benjamin Brodie, as it turned out—and her illness was finally diagnosed.

Now, Carter reports, “Whole size of mass equal to palm of hand nearly,” the pain has spread to her hips, and she is taking a long list of medications, the dosages for which he carefully notes. While a local physician visited her regularly, Carter had been closely monitoring his mother’s treatment over the past two years and, in a sense, following her case since he was a boy. He was just thirteen when she first fell seriously ill, and sixteen when, in the summer of 1847, she was diagnosed. At that very time, it is fascinating to note, Carter had just started his apprenticeship in a Scarborough medical practice, and by year’s end, he would be in London to attend the same medical school where—yes—Dr. Brodie was serving as professor emeritus. Now here’s where coincidence stops being coincidence, I believe, as mother and son’s histories merge. Though some historians have surmised that Henry Vandyke Carter chose medicine over the family business, art, because of the influence of a science-minded uncle, I think otherwise. It surely had to do with his mother. Perhaps if he became a doctor, the teenager must have thought, he could save her.

Given the gravity of her condition at Christmastime 1851, it is surprising to find Eliza Carter continuing to appear in her son’s diary. The mentions, year after year, are typically brief and blunt—“M. worse,” or “M. weaker”—like addendums to her case notes. So much so, in fact, that I started wondering if H. V. Carter ever saw her as more than just Patient M. I know of only one way to find out. I make an online visit to the Wellcome Library’s Carter catalog and do some shopping.

Just twelve letters from H.V. to his mother have survived, surely a small fraction of the number he wrote over the years, but from these, a clear and striking impression emerges. Yes, she is very much a patient in her son’s eyes, but she also plays a key role as his spiritual confidante, the only person with whom he can be nakedly honest about his struggles with faith. “Prayer is the one [subject] I have had least resort to, hardly ever,” he admits in one letter. “The Bible read daily, but how? Not prayerfully. This subject is so discouraging. You must know, dear Mother, such a turmoil within me, is very unfavourable.”

Frankly, I would have expected Carter to keep this turmoil to himself, for fear not only of burdening his frail mother but also of disappointing her. But the reality is, he felt he had no one else to turn to. Lily, Joe, and their father were nowhere near as devout as he, and, even after eight years in London, he still had not a single friend in whom he could confide. “Where shall I look for a Christian friend?” he laments again and again in his diary, most recently in February 1856. Sadly, the person with whom he spends the most time, Henry Gray, does not qualify, though Carter can see God in their relationship. “It does seem the act of a kind Providence to have brought me so much into contact with such a character,” he notes in June of the same year. Still, he yearns for “inter-communion” with like-minded others, he adds in the same entry. “I have literally none.” Even his longtime pastor does not seem very sympathetic. On two separate occasions, Reverend Martin had advised him not to write down his religious struggles—advice that, needless to say, Carter did not heed.

He poured out his troubled soul to his mother, and his letters are undeniably moving. Yet it is also hard not to see the two as tragic kindred spirits, she as her health is failing, he as his faith is failing. Just as he hoped to save her, she now wishes to save him. So close is their bond that mother and son create a private ritual. On appointed nights starting at 11:00
P.M.,
H.V. (in London) and his mother (in Scarborough) engage in an hour of “mutual prayer.” By joining together, they are amplifying their appeal to God and reinforcing “the spiritual state dear to us both,” as he describes it. But on an earthly level, they are also communing with each other in an intensely intimate way.

For all his candor, Carter is surprisingly silent on certain topics, which frustrates my inner eavesdropper. I want to hear about experiences he does not record in his daily diary. Two of the twelve letters, for instance, were written while Carter worked on
Gray’s Anatomy,
and I would have loved a bit of news on his progress, or even just a quick postscript about his artistic life. Unfortunately, he didn’t write a word; fortunately, there
was
a firsthand witness.

“Henry and I have a very (too) quiet life at present. He is at home drawing, etc., a good deal, and I am out ‘studying’ pictures a good deal,” Joe Carter reports in one of a handful of letters to Lily Carter from this period. “We generally are both home in the evening: reading, smoking (not I, yet), drawing, retiring (and reappearing next morning) rather late.”

The Carter brothers had moved here to 33 Ebury Street, their second London apartment together, in mid-August 1855. Joe had failed to get accepted into the Royal Academy—much to both brothers’ disappointment—so he was schooling himself, spending his days among the old masters at art museums. But he was not anywhere near the student H.V. had been. I get the feeling, in fact, that going out and “studying pictures” was a euphemism for roaming the galleries and eyeing the young ladies. What’s more, the anatomy lessons H.V. had given his brother apparently had not stuck. “Joe diligent,” Carter told his diary, “but progress very slow.
Cannot
draw figure.” Nevertheless, Joe, a watercolorist who, like his father, favored landscapes, certainly knew how to set a scene with just a few bold strokes, as demonstrated in a letter to Lily written not long after the boys had finished unpacking.

“We are becoming used to our new quarters,” Joe writes, adding, “of course H. is the principle [
sic
]
decider
.” Fortunately, this apartment has “two windows and two doors and two cupboards,” Joe notes playfully—as if saying, one for each of them—and it came with a sofa and an easy chair. The latter “has attracted the favourable notice of Harry,” Joe explained (apparently using a family nickname for H.V.), and the former “is dedicated to”—that is, piled high with—“drawings, folios, and other
untidy
objects.”

Joe adds more details in a later letter: H.V. uses the main room for drawing, he notes, and also for seeing “his visitors,” a reference to the medical students Carter had begun tutoring. As for himself, Joe boasts, “I have got a ‘bona fide’ attic upstairs for my studio,” evoking an image of a garret lit with candles and with pinned sketches papering the walls. Had he not been sharing the apartment with his persnickety, abstemious Christian brother, his life in London would almost sound Bohemian.

By this point, Joe, who would turn twenty-two in December 1856, had definitely begun taking himself more seriously as an artist (lest there be any doubt, he signed his letters to Lily “
J. N. Carter, Artist,
” as if imitating the signature of his idol, the English painter J.M.W. Turner). But the fact is, he was not an inspired one. I have seen some of Joe’s paintings; at best, they look inspired by his father. Ironically, the truly gifted artist was not up in the attic studio but down in the main room, drawing anatomy on wood and smoking late into the night.

H. V. Carter would never have seen himself this way, nor would he have viewed his art as Art. Art was framed and hung on a wall and admired. His work for
Gray’s Anatomy
was scientific and academic, chiefly, and, by its very nature, too morbid to be displayed or even discussed in polite company (which might explain why Carter didn’t write to his mother about it). His drawings were meant to benefit the student, not to bear evidence of his hand. Even so, even without a tiny
H.V.C.
in the corner, his style is so distinctive that I, for one, can easily tell a Henry Vandyke Carter drawing from that of an imitator.

Joe Carter also had a blind spot when it came to his own gifts, I believe. He describes himself to Lily as an “indifferent correspondent” and apologizes for his careless writing, but he was quite mistaken. He was a wonderful, evocative writer, much more so than H.V., who, despite keeping a diary for many years and writing hundreds of letters, did not have Joe’s ease of language. Lily must have loved getting her little brother’s letters. They are full of clever wordplay and fresh observations—they are, in a word, charming, as Joe must surely have been. For instance, he opened one letter to her with a lovely riff about the persistent nature of one’s own history: “It often
surprises
me to find how intimately the
past
becomes interwoven with the
present
, and the
apparent
future,” he begins. “And I have, at times,
immensely
wondered to find that what is past—the past—does not, nor
will
it, detach itself and remain where it was (or where it might have been
intended
to have remained) but it must bring itself forward, and smilingly, or otherwise, present itself as an old friend, and will not be denied. It is not till we try to remove or change old ideas or
facts
that we find how deeply rooted they are.”

OVERNIGHT, THE FUTURE
has arrived in the dissection lab: eight sleek new computers were installed on the north side of the room for the purpose of playing CD-ROMs of virtual dissections. One of them is stationed right next to our table. The CD-ROMs are an adjunct to the students’ studies and, incidentally, something to keep them occupied while waiting for a spot at the prosections table. Nevertheless, the presence of computers in the lab signals a momentous shift. This is where the study of human anatomy is headed, some experts say, to 3-D re-creations and simulations that do away with cadavers entirely.

Until then, there is still “cadaver splatter” to worry about, not to mention gunky hands. Hence, the computer keyboards and mouses are covered in Saran wrap; high tech meets low tech. There are also skeptics to convert, such as Dana Rohde. As she points out, “Why sit and watch a video or CD-ROM when you can just go dissect?”

Truth be told, Dana is not a big fan of prosections either. “Most of them are awful. They’re old, they’re dried out, and they’ve been handled by so many people.” Worse, prosections present in pieces what should be taught as a whole. “You simply can’t learn that way.”

Dana does not mince words, even between bites of a vegetarian Subway sandwich. She and I were sitting outside the Health Sciences building, between classes, on a gorgeous September afternoon. We had gotten together to catch up belatedly on our respective summer adventures—she in the Galapagos Islands with her twin sister; me, in the PT course—but talk had quickly turned to the anatomy program. Dana explained that the course I am attending is actually quite different from the one taught just a few years ago. Up until the year 2000, first-year med students at UCSF took six full
months
of anatomy, which was pretty much the standard for medical schools across the country. “Only four students per cadaver, and they dissected literally everything, from eyeballs to brains, genitals, toes. Everything.”

This “old curriculum,” as Dana called it, was indeed old, harking back to the 1830s, when legal cadavers started becoming widely available due to a change in law, first in England and, soon after, the United States. As a result, dissections by students themselves (not just by instructors and demonstrators) were feasible. The half-year-long anatomy courses that Gray and Carter took as students and taught as teachers became the norm, and, in fact, those classes were not substantially different from the ones offered 150 years later. Every other class in a modern med student’s curriculum had changed, however. For instance, Gray and Carter never had to study radiology, oncology, and immunology, nor genetics and molecular biology, the fields that have revolutionized medicine in the past fifty years. By the late twentieth century, the typical four-year med school curriculum had become so jam-packed that, short of adding another year, some courses had to be scaled back. To many administrators, the traditional six months of anatomy was starting to look like a luxury, particularly given the huge costs involved not only in acquiring and maintaining cadavers but also in staffing. As I had come to appreciate firsthand, having up to eight instructors supervising fledgling dissectors several times a week certainly must not be cost-effective.

In 2001, UCSF became one of the first medical schools in the nation to make a major move, implementing a change so radical as to cause an uproar from the students. The school eliminated the traditional anatomy course; integrated into other courses a fraction of what had formerly been taught (the anatomy of the heart and lungs, for instance, was taught in a class on the organs); and dispensed entirely with cadavers and dissecting by students. The small amount of anatomy still in the curriculum was taught with prosections. As UCSF is one of the top-ranked schools in the country, other med schools soon followed its example and started slashing their anatomy programs.

While it was an academic year Dana would rather forget, she also takes pleasure in recounting how a great many students successfully lobbied for the reinstatement of the course (albeit reduced from six months to the current six weeks, supplemented by some anatomy classes spread throughout the year) and the reenlistment of cadavers. Even so, repercussions of that failed experiment remain, as I would soon witness.