The Anatomist: A True Story of Gray's Anatomy (20 page)

Following lunch, I accompany Dana to an appointment in the dissection lab. She is meeting with two fourth-year students, a young man and woman who had been part of the test class of 2001. We find them at the back of the empty lab peering into a nightmare cookie jar, a human head with the skullcap removed. They had contacted Dana because they were about to start their ophthalmology rotation and were worried about gaps in their knowledge.

The pair bump heads over the head as Dana takes them on a quick behind-the-eyes tour, pointing out how tight the packaging is. “Now you can see why a pituitary tumor
here
gives you an optic nerve problem
here
”—the students are nodding, clearly getting it—“and why a carotid aneurysm at that level gives you a cranial nerve VI injury, which affects…” She studies their faces, waiting for a response, waiting, waiting—

“Lateral eye movement?” I offer after a long moment.

“Exactly,” Dana says. “Very good.”

I step back while Dana finishes up with the fourth-years. To their credit, it strikes me, these two young people knew they were missing something and wanted a remedy. But how do you know you don’t know something? And what about all those students who are not here in the lab?

As Dana and I return to her office, I ask, “Are you worried that these students with less anatomy training than in the past will be ill prepared as doctors?”

“Ultimately, they’ll be fine,” she says without hesitation. “They’ll know enough.”

I’m not satisfied with this answer, as Dana can tell.

“I think it’s more a question of not having that ‘total vision’ of the body,” she emphasizes, “of not understanding things as well as they could. So much of understanding anatomy is just tying it all together, and you don’t get that when you do little body parts.” At the same time, she is not unrealistic in her expectations. “I don’t expect them to become anatomists. No, I appreciate that I know the body so well, I don’t have to memorize anything. And, as you know, my big thing is, the more you understand anatomy, the less you have to memorize.”

“Yes, Dr. Dana Rohde, the anti-mnemonicist,” I say teasingly.

She laughs, then slips back into teacher mode as we stand alone in the hallway: “Take the cranial nerves, for example. Once you’ve dissected them, you can picture cranial nerve VII coming out of the brain stem and going through the skull, and you know exactly how it gets to the tongue. And likewise with cranial nerve IX—you just see it taking a totally different path to a totally different part of the tongue. And you’d never even
think
you’d have to memorize it.” You would simply
see
it, she reiterates. “That’s the vision I have.”

WE HAVE SOMETHING
that the other students are lining up to see: we have a good cadaver. Actually, that’s understating it some. A good cadaver is one in which the structures come clean easily, separate distinctly, and are not surrounded by excessive amounts of fat or obscured by calcification. What makes our body not just good but
very
good (and very popular) is that it has a fully intact reproductive system. Given that donor cadavers are generally quite elderly (the average age in this group is eighty-four) and, if female, have typically had hysterectomies, this is a rare sight. Certainly, it is my first.

Our cadaver’s uterus is about the size of a fist, lavender-colored, and supple to the touch, unlike in the prosection, by comparison, where the organ has literally shriveled to the size and texture of a walnut. What’s more, while the prosection is missing the Fallopian tubes, here they are in perfect shape, extending from the uterus in twin arcs. (Fallopian tubes are not attached to the ovaries.) At the tips of each tube are the tiny egg-grabbing fingers called fimbriae and, just below these, the ovaries, plump and almond-shaped. The stabilizing ligaments and surrounding tissue are likewise in place, clearly visible through the glossy peritoneum draped over the uterus and ovaries. In fact, the whole looks in such good working order, even in an eighty-eight-year-old body, that it is strangely easy to imagine, to
see,
the system in operation: An egg being pitched from an ovary. The fimbria, hovering overhead, catching it in its grasp. The mesosalpinx flapping gently, nudging the egg through the Fallopian tube to the uterus, where it unites with a sperm cell. And finally, in time-lapse motion, the uterus expanding, filling with life as if filling with breath.

Once you have images like this banked in your head, you cannot help viewing people’s bodies differently—
anatomically.
You see life with a kind of picture-in-picture feature, I have discovered. Your friend breast-feeding her newborn becomes an astonishing multiplex image, a body feeding a body it has created. The jogger running down your block is a churning red machine. The vision works just as well on yourself, turning even the most prosaic of actions golden. My morning pee, for instance, will never be the same.

The urge-to-go that gets me out of bed now comes with its own series of illustrations. In my mind, I can see the bladder, a small, delicate organ, stretched to capacity, like a balloon that won’t survive one more blow. I can picture it right above the chestnut-sized prostate gland and pressing against the thin muscles of the lower abdomen, making the surface of my belly feel as taut as a snare drum. In the moment before splashdown, I know that the visceral afferent nerves in my bladder are flaring, sending distress signals to my brain via the spinal cord:
Empty me now!
Once the keg is tapped, so to speak, and the pressure reduced some, a larger picture starts coming into focus. From the bladder, I can mentally trace the twin tubes of the ureters crossing the pelvic brim and ascending in graceful lines up to the kidneys. Within each kidney, I see inside the complex filtration system that has strained this thin pale yellow stream from my blood. And by the time I flush, I have glimpsed the greater complex of blood vessels leading back to, and out of, the heart.

Having a vision of how the body works also comes, naturally, with a finer understanding of how it can fail, of how the body can betray you. When my friend Richard told me over the phone recently that he had been diagnosed with kidney cancer, it was as if, before the news sank in, a slide carousel had dropped into the projector in my head: views of a kidney—anterior, posterior, hemisected—began flashing behind my eyes. As Richard talked about the symptoms that signaled something was not right with his body—drenching night sweats, fatigue—I zoomed in on the area of his lower back where the kidneys sit. I pushed deeper, peppering him with specific anatomical questions, all the while building a detailed picture in my head of his diseased organ: Which kidney—right or left? (
Left.
) Where was the tumor? (
Right on the surface; two inches in diameter.
) Had it penetrated the bedding of fat? (
Yes.
) What about the renal hilum? (
No.
)

“Well, that’s good news,” I said, visualizing how, when caught at this early stage, such a cancer probably could not spread.

“Yeah, it is,” Richard answered. “On the list of cancers to have, they say this is not a bad one. I didn’t have to have chemo or radiation. They simply removed it—” At this, I could imagine the procedure—the renal artery and vein being transected, the kidney and surrounding fat lifted out—yet I also found myself thinking,
What happens to the ureter? It must be removed, too, tied off at the bladder.

The conversation gave me a small sense of the diagnostic skill doctors in training must develop, the ability to play out possible treatment scenarios in their mind. A doctor’s vision is not always an enviable one, though, as Meri, a fellow student in the anatomy lab, helped me appreciate. One afternoon she told me about a friend of hers, a recent med school graduate, whose mother had developed a life-threatening autoimmune disease. “She
knows
how bad it is, what’s happening inside her mom,” Meri said. “But she really can’t
tell
her mom everything—it’s all too awful. And when her mom asks her questions about her condition, sometimes she just doesn’t answer. She doesn’t want to tell her mom what she knows.”

June 20, 1856
33 Ebury Street
London

Dearest ‘Ma,’

I beg of you to send for me, if you feel the least inclined, or if you think me capable of doing any good, however little. This brings me at once to a little request of yours: can I propose any remedy (marvelous! it must be) to restore you at once to health and strength? Oh! ho, dear Ma, you don’t ask
this
, do you? It is but a little thing….

If Carter sounds desperate at first, he had good reason. He had just learned that his mother’s health had taken a serious turn. But I find it all desperate, even as he tries for levity. In his dissembling, his utter helplessness is all the more palpable. Turning to his diary soon after, he reveals the depth of his fears: not only is his mother’s health failing, but now his grandfather is “dangerously ill.” He worries, “Are these shadows of coming events?”

Yes, they are. Within days, the grandfather dies and Carter returns home for the funeral. “Find M. certainly changed,” he reports. “She really does look in a sinking state—
very
pale and thin, with an anxious expression.” In the entry, Carter also notes that he has prescribed opium as well as “Quinine Chloric Ether,” an anesthetic, which suggests his mother was in considerable pain.

After this, M. all but disappears from the diary. Then comes this:

Sun., April 5, 1857

This evening, at about 9:00, the landlady brought up a Telegraphic Dispatch, which contained the words,
“Your mother died this morning. Come on Tuesday if you can, not later than Wednesday.”

Arriving home, H.V. and Joe find their mother laid out in her bedroom covered with a death shroud she had made for herself several years earlier.

Eliza Caroline Carter was forty-six years old.

In her final days, she did not send for her doctor son. “
Not that I should not be delighted to see him,
” his mother had said, a friend of the family told H.V., “
but he will sit and watch me so earnestly, and can do no good.
”

Thirteen

I
LOOK UP FROM THE BODY AND FIND THE LAB EMPTY SAVE FOR
Anne, an assistant who has been prepping dissections for the next day’s class, but she’s on her way out. “Turn off the lights when you go,” she calls, and the door springs shut behind her. It is only six o’clock but feels much later. The black October sky has turned the bank of windows into a mirror. I see myself and the class cadavers. All but mine are zipped up for the night in their white body bags.

I like being in the lab at this hour. There is a quality to the silence that reminds me of the libraries I loved as a child. My mind quiets as I focus on the task at hand, which tonight involves finishing up the day’s last assignment, a complicated dissection of the anterior thigh. I am doing this to help my lab partners, true, but also for my own edification. Since yesterday, we have been engaged in a three-day “Limb Lab,” an extensive exploration of the arms and legs, which includes studying a part of the body most people don’t even know exists: fascia.

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
No
s. 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.