A Historical Introduction To Gray’ s Anatomy
BY: RUTH RICHARDSON
The shortcomings of existing anatomical textbooks probably impressed themselves upon Henry Gray when he was still a student at St George’s Hospital Medical School, near London’s Hyde Park Corner, in the mid-1840s. He began thinking about creating a new anatomy textbook a decade later, while war was being fought in the Crimea. New legislation was being planned which would establish the General Medical Council (1858) to regulate professional education and standards.
Gray was now twenty-eight years old, and a teacher himself at St George’s. Although little is known about his personal life, we do know he was very able and highly ambitious, already a Fellow of the Royal Society, and of the Royal College of Surgeons. His was a glittering career thus far, achieved while he served and taught on the hospital wards and in the dissecting room.
Gray shared the idea for the new book with a gifted artistic colleague on the teaching staff at St George’s, Dr Henry Vandyke Carter, in November 1855. Neither was interested in producing a pretty book, or an expensive one. Their purpose was to supply an affordable, accurate teaching aid for students like their own, who might soon be required to operate on soldiers injured at Sebastopol or some other battlefield. The book they planned together was a practical one, designed to encourage youngsters to study anatomy, help them pass exams, and assist them as budding surgeons.
Now, at the turn of the twenty-first century, in this 39th edition of Gray's Anatomy, we can look back over nearly 150 years of continuous publication to consider the long term value of their efforts, to discern how the book they created triumphed over its competitors, and survived pre-eminent.
Gray and Carter belonged to a generation of anatomists ready to infuse the study of human anatomy with a new, and respectable, scientificity. Disreputable aspects of the profession’s history, acquired during the days of bodysnatching, were assiduously being forgotten. The Anatomy Act of 1832 had legalised the requisition of unclaimed bodies from workhouse and hospital mortuaries, and the study of anatomy (now with its own Inspectorate) was rising in respectability in Britain. The private anatomy schools which had flourished in the Regency period had finally closed their doors, and the major teaching hospitals were erecting new purpose-built dissection rooms.
The best-known student works when Gray and Carter had qualified were probably Erasmus Wilson’s Anatomist’s Vade Mecum, and Elements of Anatomy by Jones Quain. Both works were small - pocket-sized - but Quain was a ‘triple-decker’ in three volumes. Both were good books in their way, but their small pages of dense type, and even smaller illustrations, were somewhat daunting, seeming to demand much nose-to-the-grindstone effort from the reader.
The planned new textbook’s dimensions and character were serious matters. Pocket manuals were commercially successful because they appealed to students by offering much knowledge in a small compass. But pocket-sized books had button-sized illustrations. Knox’s Manual of Human Anatomy, for example, was only six inches by four (17x10 cm) and few of its illustrations occupied more than a third of a page. Gray and Carter must have discussed this between themselves, and with Gray’s publisher JW Parker & Son, before the decision was finalised.
The two men were earnestly engaged for the following eighteen months in the work which would form the basis of the book. All the dissections were undertaken jointly, Gray wrote the text, and Carter the illustrations. Their working days were long, all the hours of daylight, eight
or nine hours at a stretch - right through 1856. We can infer from the warmth of Gray’s appreciation of Carter in his published acknowledgements that their collaboration was a happy one.
{ The Author gratefully acknowledges the great services he has derived in the execution of this work, from the assistance of his friend, Dr HV.Carter, late Demonstrator of Anatomy at St George’s Hospital. All the drawings from which the engravings were made, were executed by him. }
With all the dissections done, and Carter’s inscribed blocks at the engravers, Gray took six months leave from his teaching at St George’s, to see the book through the press. Carter sat the examination for medical officers in the East India Company, and sailed for India in the spring of 1858, when the book was still in its proof stages. Gray was assisted in the checking of the galley proofs by an older colleague, Timothy Holmes, whose association with the book would later prove vital to its survival.
The First Edition
The book Gray and Carter created, Anatomy Descriptive and Surgical appeared in August 1858, to immediate acclaim. Reviews in the Lancet and British Medical Journal were highly complimentary, and students flocked to buy.
It is not difficult to understand why it was a runaway success. Gray’s Anatomy knocked its competitors into a cocked hat. The book holds well in the hand, it feels substantial, it contains everything required It was smaller and more slender than the doorstopper with which modern readers are familiar. To contemporaries it was small enough to be portable, but large enough for decent illustrations: ‘octavo’ - nine-and-a-half inches by six (24x15cm) - about two-thirds of modern A4 size. Its medium size, single volume format was far removed from Quain, yet double the size of Knox’s Manual.
Simply organised and well designed, the book explains itself confidently and well: the clarity and authority of the prose is manifest. But what made it unique for its day was the outstanding size and quality of the illustrations. Gray thanked the wood engravers Butterworth and Heath for the ‘great care and fidelity’ they had displayed in the engravings, but it was really to Carter that the book owed its extraordinary success.
The beauty of Carter’s illustrations resides in their diagrammatic clarity, quite atypical for their time. Contemporary anatomical images were usually proxy labelled: dotted with tiny numbers or letters, or bristling with a sheaf of numbered arrows, referring to a key situated elsewhere. Proxy labels require the reader’s eye to move to and fro: from the structure to the proxy label to the legend and back again. Carter’s illustrations, by contrast, unify name and structure, enabling the eye to assimilate both at a glance. The volume made human anatomy look new, exciting, accessible, and do-able.
The spine of the first edition read:
GRAY
ANATOMY
CARTER
... with both surnames in equal sized type. Carter was given equal credit with Gray on the book’s titlepage for undertaking all the dissections on which the book was based, and sole credit for all the illustrations.
Gray was paid £150 for every thousand copies sold, but Carter received no royalty payments: only a one-off fee at publication, which may have allowed him to purchase the long-desired microscope he took with him to India.
The first edition print-run of 2000 copies sold out swiftly. An edition was published in the United States in 1859, and Gray must have been deeply gratified to have to revise and pilot an enlarged new English edition through the press in 1860, though he was surely saddened and worried by the death of John Parker junior, aged 40, that same year. The second edition came out in December, and, it too, sold well.
The following summer, in June 1861, at the height of his powers and full of promise, Henry Gray died suddenly at the age of only 34. The country was already in mourning for the death of Prince Albert. Gray had contracted smallpox while nursing his little nephew Charles, and although he had been vaccinated in infancy the disease became confluent, and Gray died within days.
The book Survives
Anatomy Descriptive and Surgical could have died too. With Carter in India, the death of Gray, so swiftly after the younger Parker, might have spelled catastrophe. Certainly, at St George’s there was a sense of calamity. The grand old medical man Sir Benjamin Brodie, Sergeant-Surgeon to the Queen, and a great supporter of Gray to whom Anatomy had been dedicated, cried forlornly: “Who is there to take his place?”
But old JW Parker ensured the survival of Gray’s by inviting Timothy Holmes, the doctor who had helped proof-read the first edition, and who had filled Gray’s shoes at the medical school, to serve as editor for the next edition. Other long-running anatomy works remained in print in a similar way: Quain for example, was co-edited by other hands.
Holmes (1825-1907) was another gifted George’s man. A scholarship boy who won an exhibition to Cambridge, where his brilliance was recognised. Holmes had been a Fellow of the Royal College of Surgeons at 28. John Parker junior had commissioned Holmes to edit A System of Surgery, (1860-64) an important essay series by distinguished surgeons on subjects of their own choosing. Many of Holmes’s authors remain important figures, even today: John Simon, James Paget, Henry Gray, Ernest Hart, Jonathan Hutchinson, Brown Séquard, and Joseph Lister. Holmes lost an eye in an operative accident, and had a gruff manner which terrified students, yet he published a lament for young Parker which reveals him capable of deep feeling.
John Parker senior’s heart, however, was no longer in publishing. His son’s death had closed down on the future for him. The business, with all its stocks and copyrights, was sold to Messrs Longman. Parker retired to the village of Farnham, where he later died.
With Holmes as editor, and Longmans as publisher, the immediate future of Gray’s Anatomy was assured. The third edition appeared in 1864 with relatively few changes, Gray’s estate receiving the balance of his royalty after Holmes was paid £100 for his work.
The missing obituary
Why no obituary appeared for Gray in Gray’s Anatomy is curious. Gray had referred to Holmes as his ‘friend’ in the preface to the first edition, yet it would also be true to say that they were rivals. Both had just applied for a post at St George’s, for Assistant Surgeon. Had Gray lived, it is thought that Holmes may not have been appointed, despite his seniority in age.
Later commentators have promulgated the mistaken idea that Holmes’s ‘proof-reading’ included improving Gray’s writing style, which is probably a reflection of Holmes’s own self-regard. There can be no doubt that as editor of seven editions of Gray’s Anatomy, Holmes added new material, and had to correct and compress passages, but Gray’s original writing style was lucid, in this as in other works.
It may be that Gray’s glittering career or perhaps the patronage which unquestionably advanced it created jealousies among his colleagues; or that there was something in Gray’s manner which precluded affection, or which created resentments among clever social inferiors like Carter and
Holmes. Whatever the explanation, no reference to Gray’s life or death appeared in Gray’s Anatomy until the twentieth century.
A succession of Editors
Holmes expanded areas of the book which Gray himself had developed in the 2nd edition (1860), notably in ‘general’ anatomy (histology) and ‘development’ (embryology). In Holmes’s era the volume grew from 788 pages in 1864 to 960 in 1880 (9th edition), with the histological section paginated separately in roman numerals at the front of the book. Extra illustrations were added, mainly from other published sources.
The connections with Gray, Carter and with St George’s were maintained with the appointment of the next editor, T. Pickering Pick, who had been a student at St George’s in Gray and Carter’s time. From 1883 (10th edition) onwards, Pick kept up with current research, rewrote and integrated the histology and embryology into the volume, dropped Holmes from the titlepage, removed Gray’s preface to the first edition, and added emboldened subheadings which certainly improved the appearance and accessibility of the text. Pick said he had “tried to keep before himself the fact that the work is intended for students of anatomy rather than for the Scientific Anatomist.” (13th ed.1893)
Pick also introduced colour printing (in 1887, 11th edition) and experimented with the addition of illustrations using the new printing method of half-tone dots: for colour (which worked) and for new black-and-white illustrations (which didn’t). Half-tone shades of grey compared poorly with Carter’s wood engravings, still sharp and clear by comparison.
What Henry Carter made of these changes is a rich topic for speculation. He returned to England in 1888, having retired from the Indian Medical Service, full of honours - Deputy Surgeon General, and in 1890, was made Honorary Surgeon to Queen Victoria. Carter died in Scarborough in 1897, aged 65. Like Gray, he received no obituary in the book.
When Pick was joined on the titlepage by Robert Howden (a professional anatomist from the University of Durham) in 1901 (15th edition), the volume was still easily recognisable as the book Gray and Carter had created. Although many of Carter’s illustrations had been revised or replaced, many still remained. Sadly, though, an entire section (embryology) was again separately paginated, as its revision had taken longer than anticipated. Gray’s had grown, seemingly inexorably, and was now quite thick and heavy, 1244 pages weighing 5lb8oz/2.5kilos. Both co-editors, and perhaps also its publisher, were dissatisfied with it.
Key edition: 1905
Serious decisions were taken in advance of the next edition, which turned out to be Pick’s last with Howden. Published 50 years after Gray had first suggested the idea to Carter, the 1905 (16th edition) was a landmark edition.
The period 1880-1930 was a difficult time for anatomical illustration, because the new techniques of photolitho and half-tone were not as yet perfected, and in any case could not provide the bold simplicity of line required for a book like Gray's which depended so heavily on clear illustration. Recognising the inferiority of half tone illustrations to Carter’s wood engraved originals, Pick and Howden courageously decided to jettison them altogether. Most of the book’s new illustrations and even some older ones, were newly commissioned wood engravings or line drawings, intended ‘to harmonise with Carter’s original figures’, and they did successfully emulate Carter’s verve. Having fewer pages and lighter paper, the 1905 (16th edition) weighed less than its predecessor, at 4lb11oz/2.1 kilos. Typographically, the new edition was superb.
Howden took over as sole editor in 1909 (17th edition) and immediately stamped his personality on Gray’s. He excised “Surgical” from the title, changing it to Anatomy Descriptive and Applied,
and removed Carter’s name altogether. He also instigated the beginnings of an editorial board of experts for Gray’s, by adding to the titlepage: ‘Notes on Applied Anatomy’ by AJ Jex-Blake, and W Fedde Fedden, both St George’s men. For the first time, the number of illustrations exceeded one thousand. Howden was responsible for the significant innovation of a short historical note on Henry Gray himself, nearly 60 years after his death, which included a portrait photograph (1918, 20th edition).
The Nomenclature controversy
Howden’s era, and that of his successor TB Johnston (of Guy’s) was overshadowed by international controversy concerning anatomical terminology. European anatomists were endeavouring to standardise anatomical terms, often using Latinate constructions, a move resisted in Britain and the United States. Gray’s became mired in these debates for over twenty years. The endeavour to be fair to all sides by using multiple terms doubtless generated much confusion amongst students, until a working compromise was arrived at, in 1955 (32nd edition, 1958).
Johnston oversaw the second retitling of the book (in 1938, 27th edition): it was now, officially, Gray’s Anatomy, finally ending the fiction that it had ever been known as anything else. Gray’s suffered from paper shortages and printing difficulties in World War II, but successive editions nevertheless continued to grow in size and weight, while illustrations were replaced and added as the text was revised. Between Howden’s first sole effort (1909, 17th edition) to Johnston’s last edition (1958, 32nd edition) Gray’s expanded by over 300 pages - from 1296 to 1604 pages, and almost 300 additional illustrations brought the total to over 1300. Johnston also introduced X-ray plates (1938) and in 1958 (32nd edition) electron micrographs by AS Fitton-Jackson, one of the first occasions on which a woman was credited for a contribution to Gray’s. Johnston felt compelled to mention that she was “a blood relative of Henry Gray himself”, perhaps by way of mitigation.
After World War II
The editions of Gray’s issued in the decades immediately following the Second World War give the impression of intellectual stagnation. Steady expansion continued in an almost formulaic fashion, with the insertion of additional detail.
The central historical importance of innovation in the success of Gray’s seems to have been lost sight of by its publishers and editors - Johnston (1930-58, 24th to 32nd editions); J. Whillis (co-editor with Johnston 1938-54) D.V.Davies (1958-1967, 32nd to 34th editions) and F. Davies (co-editor with D.V.Davies 1958-64, 32nd to 33rd editions). Gray’s had become so pre-eminent that perhaps complacency crept in, or editors were too daunted or too busy to confront the ‘massive undertaking’ of a root and branch revision.7 The unexpected deaths of three major figures associated with Gray's in this era, James Whillis, Francis Davies, and David Vaughan Davies - all of whom had been groomed to take the editorial reins - may have contributed to ####### the process. The work became somewhat dull.
Key Edition: 1973
D.V.Davies had recognised the need for modernisation, but his unexpected death left the work to other hands. Peter Williams, who had been involved as an indexer for Gray’s for several years, and Roger Warwick (both Professors of Anatomy at Guy’s) regarded it as an honour to fulfil Davies’ intentions.
Their 35th edition of 1973 was a significant departure from tradition. Over 780 pages (of HOW MANY) were newly written, almost a third of the illustrations were newly commissioned, and the illustration captions were freshly written throughout. With a complete resetting of the text in larger double column pages, a new index, and the innovation of a bibliography, this edition of Gray’s looked and felt quite unlike its 1967 (34th edition) predecessor, and much more like its modern incarnation.
This 1973 edition departed from earlier volumes in other significant ways. The editors made explicit their intention to try to counter the impetus towards specialisation and compartmentalisation in twentieth century medicine, by embracing and attempting to reintegrate the complexity of the available knowledge. Warwick and Williams openly renounced the pose of omniscience adopted by many textbooks, believing it important to accept and mention areas of ignorance or uncertainty. They shared with the reader the difficulty of keeping abreast in the sea of research, and accepted with a refreshing humility the impossibility of fulfilling their own ambitious programme.
Warwick & Williams’s 1973 edition had much in common with Gray and Carter’s first edition. It was bold and innovative: respectful of its heritage, while also striking out into new territory. It was visually attractive and visually informative. It embodied a sense of a treasury of information laid out for the reader.8 It was published simultaneously in the United States, (the American Gray’s had developed a distinct character of its own in the interval),7 and sold extremely well there.
The influence of the Warwick and Williams’s edition was forceful and long-lasting, and set a new pattern for the following quarter century. As has transpired several times before, wittingly or unwittingly a new editor was being prepared for the future: Dr Susan Standring, who created the new bibliography for the 1973 edition of Gray’s, went on to serve on the editorial board, and is now the Editor of the current edition (2004, 39th edition).
The doctor’s bible
Neither Gray nor Carter, young men who - by their committed hard work between 1855 and 1858 - created the original edition of Gray’s Anatomy, would have conceived that years after their deaths their book would not only be a household name, but regarded as a work of such pre-eminent importance that a novelist half a world away would rank it as cardinal - alongside the Bible and Shakespeare - to a doctor’s education.9 With this fine new edition, their book goes marching on.