by Bill Hayes
Back at my table, Massoud and the others are stuck in the mass of confusion known as the small intestine. Gray describes this part of our anatomy as “a convoluted tube,” as if he, too, had gotten lost here once or twice. The group backtracks to the stomach and begins again. It is easy to find the first part of the small intestine, the duodenum, because it is the first ten inches (twenty-five and a half centimeters) off of the stomach. (Duodenum comes from the medieval phrase meaning “intestine of twelve fingerbreadths.”) Here is where most ulcers occur. The remaining nineteen or so feet (six meters) of the small intestine is composed of, first, the jejunum, followed by the ileum, which eventually leads into the large intestine. Had we tipped our cadaver to the side, the intestines would not have just poured out, and neither could we have simply pulled them out, foot by foot, the way you see in gory movies. Connective tissue keeps the twisting mass contained in the abdominal cavity but able to roil freely during the digestive process.
The large intestine, about five feet (one and a half meters) in length, frames the small intestine on three sides and comes in four main sections: the ascending colon up the right shank; the transverse colon across the abdomen at the level of the bottommost rib; and the descending colon down the left, which then turns into the S-shaped sigmoid colon and feeds into the rectum. By any name, bowels are bowels and unbeautiful, but serve a necessary purpose. Within these coils is where water is extracted from what has been digested and what remains is turned into what will be flushed.
“Oh, Bill, did you see this?” Miriam asks, nudging a pinkie-sized flap of tissue that, in fact, I had not noticed.
“The appendix,” she says at the same moment I recognize it.
I love it when an anatomical term comes with a built-in mnemonic. True to its name, the appendix is appended to a corner of the large intestine. A handbreadth away is an organ that’s completely unmissable, the liver, filling the upper right abdominal cavity. Whether viewed in situ or displayed on a specimen tray, the liver is an impressive sight, large and smooth, with perfect lines and a broad surface. It almost looks sculptural. One can see why early philosophers and physicians were fooled by its appearance. Plato, in a dialogue on natural science and cosmology from the fourth century B.C., asserted that the liver played a key role in the maintenance of the soul by keeping the organs of the abdomen in line. The liver did this through its smooth, shiny surface, which reflected images sent from the “divine psyche,” the immortal source of rationality housed in the head. Six centuries later, Galen called the liver the seat of life; hence its name, evolving from an ancient root, leip, associated with “life” or “living,” which later became lifer and, finally, the familiar term, liver. Galen believed that the liver produced blood—the life force—from digested food, which explained why the liver “clasps” the stomach, he wrote, “as if by fingers.” Further, the liver released into the bloodstream Natural Spirits, an incorporeal substance that provided the body’s mass.
In reality, this organ filters toxins and medications from the bloodstream; converts blood sugar into usable energy; produces and secretes bile, a substance that helps the intestines digest fats; and performs hundreds of other functions. But the liver also possesses a remarkable ability that can compete with the fantastical beliefs of old: alone among the major organs, it can regenerate. In a liver transplant, for example, if you remove half a liver from a healthy donor, the donor’s remaining organ will grow back to its former size. And, even more amazing, the half liver transplanted into a recipient will grow to the exact size of the recipient’s own original liver. Now, it is impossible to explain why the liver would do this. (As Dana would say, “In anatomy, you can’t ask why. It just is; that’s how we were made.”) But to me, it is hard not to see something of the miraculous in it. We are each meant to be a certain way, and our bodies make it so, as if predestination were encoded in our anatomy.
PONDERING HIS FUTURE on the eve of his nineteenth birthday, H. V. Carter summed up his prospects in two sentences: “With energy and perseverance much may be done and without either, nothing can be done. Two roads: to mediocrity and [to] eminence.”
Which one would he take?
Mediocre or eminent: which would he be?
Though the occasion was special, the dichotomy was typical. To young Mr. Carter, as exacting as he is earnest, everything is black and white—and Gray. Henry Gray starts appearing in the diary almost every day after being promoted to house surgeon in late June 1850, two weeks into the spleen project. Carter goes on daily rounds with him and witnesses his bedside manner, no doubt, as well as how he interacts with medical students and fellow doctors. Less than a week goes by before Carter begins making inquiries about what it takes to become house surgeon; clearly, he has got a goal in sight. He approaches Dr. Tatum, Gray’s mentor, who says that it normally takes at least six years. Six whole years? Seeking a second opinion, he has the same conversation with Gray, with whom he has a growing friendship. You could do it in half that time, Gray tells him, paying the younger man a fine compliment—Gray, after all, had needed four and a half years to obtain the appointment. But in Carter’s mind, he had his work cut out for him. Compared to his friend, he saw many failings in his own character. He describes himself as “indecisive,” “very slothful,” “diffident,” “not confident,” and, over and over again, “idle.” Even after the busiest days, jam-packed with schoolwork, hospital work, and artwork, he reprimands himself. “Must work more.” “Must work better.” “Must be more exact.” Must, in fact, must be the most frequently used word in Carter’s vocabulary.
So extreme is his self-criticism—and so contrary to the record of his achievements—I actually wonder if Carter had a kind of personality dysmorphic disorder. His diary is the mirror he looks into at the end of each day, and all of his accomplishments appear distorted. However, in his writing, I also hear the voice of a young man who is trying to push himself, to prove himself, to break the mold. A young man who is determined not to be like his father.
Henry Barlow Carter does not make many appearances in his son’s diary, but when he does, he leaves an unforgettable impression. One need turn back only a few pages to find a choice example. It is a month earlier, May 24, 1850, and Carter has just learned that his father is going to be “in town” the next day. But the visit gets off to a rocky start. Rather than contacting his son directly with the details of the two-week visit, Mr. Carter instead notifies Dr. Sawyer. “Don’t see why Father not write to me,” H.V. complains on the eve of Henry Carter Sr.’s arrival.
Carter had lived in London for two and a half years by this point, and although he did not consider himself as worldly as other Londoners, he had matured considerably. Just working at St. George’s, its wards crowded with the sick and dying, had been a crash course in growing up. Nevertheless, his father still treats him as if he had never left Scarborough. On their third evening together, for instance, he sits his son down and gives him a “lesson and hints” in art, just as he had throughout H.V.’s childhood. I am sure Mr. Carter felt this was a fine way to spend the time. If his son did not, though, I can’t blame him. After all, he no longer considered himself a “student” of drawing; Dr. Hewett and others at St. George’s certainly did not think so. Further, he was working in a completely different style from his father.
Even from a vantage point of a century and a half, it is easy to see that the two Carters are headed for a blowout. Two days later comes the damage report: “Have acted foolishly, hastily and improperly…. Father much put out. Say hard things.” Next comes the silent treatment: Henry Sr. tells Henry Jr. that he does not wish to see him for a few days. By the end of the week, they have made peace, attending church together, but soon thereafter hackles are raised anew. “He, irritable and annoying,” Carter scribbles on the night of Wednesday, June 5. “Self, irritated and hasty.”
If Henry Barlow Carter had kept a diary, I would bet his entry of the same night would have read something like, “He, sullen and ungrateful.
Self, short-tempered and harsh.” These two were following a script that’s been played out since the dawn of civilization: teenager wants to be seen as an adult; parent thinks teenager has a long way to go. In a bittersweet final scene, our two protagonists meet the night before the father leaves London, and they reach an accord. With that, “Bade good bye,” the son writes in his diary.
Whether Carter’s father said all the right things or all the wrong things that last night, one thing is certain: the effect on H.V. was galvanizing. Soon after his father’s departure, he added a new “must” to his running list: “Must depend on self.” Within a forty-eight-hour period, he formed the collaboration with Henry Gray and made two telling moves: He designed an elaborate box to hold his art supplies and ordered “calling cards” for himself. “HENRY VANDYKE CARTER, SAINT GEORGE’S HOSPITAL,” they read. With every letter he paid to have printed, it’s as though he were underscoring his new identity: I Am My Own Man.
No doubt about it, Henry Gray, whom Carter always characterizes in glowing terms—“capital worker,” “nice fellow,” an “example of industry and perseverance!”—is the kind of person he aspired to be. Yet it is also clear that Carter was following his own distinct path. For instance, he was studying for an apothecary license, a credential Gray never pursued. To modern ears, apothecary sounds like a quaint synonym for pharmacist or pharmacy, it being one of those odd nouns that applies equally to both a person and a place. And, in fact, in England and in much of Europe from the early to the late Middle Ages, an apothecary was exactly that: a druggist who sold drugs in a retail shop, an apothecary. By the time Carter was in medical school, however, this definition was already antiquated. Being an apothecary was actually more like being a modern-day general practitioner, a doctor with a broad knowledge of diagnosing and treating diseases. Whereas Henry Gray was well on his way toward a career in clinical surgery and research, H. V. Carter ultimately hoped to be a country doctor.
By the summer of 1850, Carter had successfully completed two years of medical school. While he had excelled at anatomy, chemistry, and botany, winning top class prizes in all three subjects, one of his prouder achievements had occurred with far less fanfare: “Made coup d’essaie at bleeding,” he noted on April 9, meaning he had made his first attempt—or, stab—at bloodletting a patient. As he went on to detail, he had divided the procedure into two “operations”: cutting into the skin to expose a vein, then slicing it open. “Not a favorable subject,” he added, suggesting that the patient was none too thrilled with being Carter’s guinea pig. Other days found Carter practicing other necessary skills: “Pulled out tooth of soldier. Tugged at another.” Over the next few years, he would have to master minor surgeries such as these, a routine part of an apothecary’s practice, and he would need to earn a degree in surgery. Finally, in order to obtain an apothecary license, Carter would have to complete a five-year apprenticeship. He was now more than halfway there.
John Sawyer, the doctor to whom he was “indentured,” was a surgeon and an apothecary and something of a holdover from earlier times. Along with his medical practice, he ran an apothecary—excuse me, a dispensary, as retail drugstores were now called. While a patient would typically get a written prescription from his apothecary and take it elsewhere to be filled, Dr. Sawyer still offered the traditional one-stop shopping. If you happened to step into his shop at 101 Park Street, you might have found his apothecary apprentice behind the counter. H. V. Carter occasionally filled in as the dispensary’s dispenser, the person who counted pills and filled prescriptions for laudanum and tincture of belladonna and black draught and so on. Not that he liked it. “Am determined to have as little as possible to do with shop and prescriptions,” he once wrote, “which [I] consider as altogether foreign to duty and [a] source of much annoyance.” There was, however, one order he always filled without complaint: his mother’s.
An apothecary in an apothecary, c. mid-nineteenth century
Eliza Carter is a mysterious figure in her son’s diary. She never comes in person to the dispensary and, in fact, has never even visited H.V. in London. She is apparently too ill to leave Scarborough, though what’s wrong with her and what drug she needs are not yet spelled out. She exists on the page only as M. “More pills for M.,” Carter might jot, meaning he had received a letter from her with a request for medication. In response, he does something that is almost impossible for me to imagine a pharmacy student today doing: he makes the pills himself.
How? He doesn’t say. But then, for good or bad, a diarist is beholden only to his own inner narrative. He does not need to explain such things to himself.
Thankfully, the details of nineteenth-century pharmacology are well documented. Pills began as a paste. The dutiful son would have carefully measured his medicinal ingredients, ground them with mortar and pestle to a fine powder, and added a liquid binding agent. Then he would mix. The importance of thorough mixing could not be overstated because each small pill had to have the same potency when the process was completed. Next came the “pill machine,” a simple, hinged apparatus that operated like a waffle iron, albeit without the waffle pattern or the heat. The machine pressed and molded the paste into neat rows of pencil-thin pipes. Finally, perhaps after some hardening had occurred, Carter would use a separate instrument to cut the pipes into their proper lengths, thus creating identical-sized pills. These had to dry before he could package them.
To think about each step Carter took is to be reminded that Rx, the symbol for prescription, is a Latin abbreviation for recipe, a word that, to me, always conjures up home-cooked meals and a mother’s love. There is something so poignant about the role reversal at play here, the child being a provider of sorts. No doubt, it gave the young Carter great pride to help his mother, even though he was far from home. Whenever he mentions the pill making, he comes across as efficient and capable—professional. Even so, the intensely personal nature of the task could not have been far from his mind. After all, these were pills destined for his mother’s body, and I get the sense that she needed them urgently. Carter moves as quickly as the process allows but, as indicated in his diary, always takes the time to write a letter to his mother to accompany them. The following morning, without fail, the package is on its way to Scarborough.
ONE CANNOT PICTURE the path of a pill through the body without studying the mouth and throat. Which means seeing the cadaver’s face, something we had managed to avoid until now. Though I’m not looking forward to this unveiling, I am curious, frankly. Over the past eight weeks, I have constructed a mental image of this frail tiny old woman. I am sure Massoud, Laura, and the others have done the same. Unlike other groups in our lab, though, we have never named our cadaver; that seemed inappropriate somehow. Perhaps my lab partners thought as I did: How can you name someone without looking into their eyes? How can you ever thank them?
Massoud lifts the cheesecloth veil, folds it back over her hair, and takes a step back. Before us is not a face like any we could have imagined. Instead, we are looking at what an anatomist would call the underlying anatomical structure of the anterior aspect of the head. Translation: a face without the skin. Like all of the cadavers in the room, our body had been partially dissected in another class, but none of us had anticipated the extent of that work. The eyes are closed and intact, as are the lips, but the fat that typically pillows in the cheeks has all been cleaned away. What remains is a mask of musculature, forehead to chin, ear to ear. Running over this is a latticework of blood vessels (empty of blood), facial nerves, and lymph ducts, all in faded shades of white. The dissection is flawless, worthy of a fine-ink drawing by H. V. Carter, and, as Gergen is quick to point out, way too good to have been done by a first-year pharmacy student. Our job for the first hour of lab—identifying specific parts of the face, such as the nerves behind a blink and the muscles that make a yawn possible—has been made textbook-easy.
In front of each ear we find a body part that almost begs a description in the form of a riddle: what
lies unseen just under the skin of the face and produces a clear, tasteless, odorless fluid? If you answered, salivary gland, you are half right, but if you said, parotid gland, you’re dead-on. The parotid, the largest of the three pairs of salivary glands, is surprisingly huge. I lift my fingers to my face just to confirm that I have a pair, and feel a distinct padding over the back curve of my lower jaw. I had always mistaken this for facial fat when, in fact, these are saliva factories. They provide our natural mouthwash, make it possible to lick our lips, and play a major role in the ability to taste. At the same time, they can be defeated by a saltine and, when their function is inhibited by certain medications, can cause dry or “cotton mouth.”
To locate the next several items on our lab list, we have to turn to Dana, who arrives at our table with a very large sealed Tupperware container and the sound of sloshing. She first warns us that what lies within may be upsetting to see. Even so, I am nowhere near prepared for what follows. Setting the lid to the side, Dana reaches down with gloved hands and lifts out what I can only describe as a horror: a severed head, split clean down the middle. A human profile from the inside out. I can see between her carefully placed fingers that the face, male, is intact.
