by Bill Hayes
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.
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 Telegr
aphic 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.
