Now in its 40th edition, 'Gray’s Anatomy' is the definitive medical reference for the human body. While the famous book bears the name of 19th century anatomist Henry Gray, it owes just as much to its largely forgotten original illustrator, Henry Carter, writes Amanda Smith.

When it comes to reference books, some names have become so familiar they just seem to belong together: Roget's Thesaurus, Encyclopaedia Britannica and Gray's Anatomy. First published in 1858, Gray's Anatomy has been continuously revised and reprinted ever since. It's also entered into popular culture thanks to long-running US television medical drama Grey’s Anatomy. In reality, the making of the book was itself something of a medical drama.

In mid-19th century London, Henry Gray was an up-and-coming young anatomist, surgeon and fellow of the Royal Society. He was well connected and on the fast track to success. The book was probably his idea, even though there were a number of other anatomy references available at the time.

Carter, because of his religious background, sees the human body as the image of God. If you think the human body is the image of God, then you're not going to treat it badly in illustrations; you're going to treat it with dignity. Ruth Richardson, author

Ruth Richardson, the author of The Making of Mr Gray's Anatomy, says the reference’s immediate success owed more to its comprehensiveness than originality. 'Gray was a good anatomist and he took information from lots of different sources and made it into a sort of definitive description for the time, written from his experience as an anatomist plus all the anatomy books he'd been using,' she says.

The special thing about the book, according to Richardson, is the illustrations. They weren’t done by Gray, but by another Henry: Henry Vandyke Carter. The two met at St George's Hospital in London where Gray was lecturing in anatomy and Carter was a demonstrator. Both were in their twenties, but Carter was provincial, deeply religious, nonconformist and socially inferior to Gray.

'[Carter was] a very interesting man who has really got lost, and I partly wrote the book to put him back on the world map,' says Richardson. 'Carter was quite an introvert, but ambitious. He knew he was very intelligent and he knew he had potential, but he thought one should succeed in the world by one's own merits, which is a very nonconformist way of behaving.'

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Gray, on the other hand, had no qualms about pulling strings and taking advantage of others. He'd engaged Carter to do the illustrations for previous publications without crediting him. Carter was therefore reluctant to get involved with the Gray's Anatomy project. His reservations were well-founded, as we shall see, but he agreed in the end because he needed the money.

The title page of the first edition makes it clear that this anatomy book was created through dissections performed jointly by Gray and Carter. It reminds you that the drawings are of real people. Who were they, and by what process did Gray and Carter get their bodies for dissection? Richardson says they were all nameless and poor: 'They came out of the hospital mortuary or out of a workhouse where they had died.'

An act of parliament had been passed in Britain in 1832 that was designed to put an end to body snatching and the trade in cadavers. This was a good thing, but it made it permissible to use the bodies of poor people for medical dissection. 'If you died in a workhouse or a hospital and you didn't have enough money for your own funeral, you could be taken for anatomy,’ says Richardson. ‘That created such an upset in the culture and [gave rise to] tremendous fear of hospitals and workhouses.'

Nevertheless, Carter represented these nameless dead with reverence. 'Carter, because of his religious background, sees the human body as the image of God,’ says Richardson. ‘If you think the human body is the image of God, then you're not going to treat it badly in illustrations; you're going to treat it with dignity. So he looks at these people, who are the poorest of the poor, as though he's mapping the human body as an image of God. If you look at the faces and the postures of the bodies in that first edition you'll see that they've got a dignity to them, which is quite unlike illustrations in contemporary anatomy books.'

Gray's Anatomy was produced during what medical historian Richard Barnett calls a golden age in medical image-making. 'Through the 18th century into the 19th century you get an explosion in medical schools and anatomy schools throughout Europe and the US. At the same time of course is the industrial revolution, so there are new techniques of mass printing. These 19th century mass-produced textbooks are responding to this new demand from a very large number of medical students and people wanting to study anatomy.'

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Barnett, the author of The Sick Rose: Disease and the Art of Medical Illustration, says that Gray's Anatomy met this demand exceedingly well. It was cheap, readily available and accurate. There was another reason for its appeal, however. The simplicity of its woodcut illustrations harked back to Renaissance anatomies such as that produced by Vesalius. Paradoxically, the 19th century was also the dawn of the age of photography.

'It's fascinating that just as photography is coming in as a technique, older traditions of anatomical image making are becoming simpler,’ says Barnett. ‘They're not becoming more complex like photographs, they're actually becoming simpler, like the illustrations in Gray's.’

‘I think that the great success of Gray's is partly due to the fact that on the one hand it looks backwards to the tradition of Vesalius, but on the other hand it looks forward to the 20th century. It looks forward to engineering blueprints and schematic diagrams of circuitry and the ways that we've come to accept knowledge being represented.'

Another feature of Gray's Anatomy is the size of the illustrations. Other 19th century anatomy books had very small drawings, annotated with letters and numbers referring to labels and descriptions in footnotes

‘Your eye is constantly jumping from the illustration down to the footnote and back and it's really difficult to use,’ says Richardson. ‘But in Gray's the size made such a difference, because they're basically maps of anatomy with the captions written on the structures. So if you look for a particular muscle, you'll see the muscle and the name runs along it. You can learn so much more easily.'

What became one of the defining features of the book, however, was very nearly its downfall. The engravings were much bigger than they should have been. Carter had drawn directly on to woodblocks that were too large to fit within the margins of the printed book.

'I'm not certain how it happened, but I suspect it was something to do with Gray thinking he knew what he was doing and actually not having a real understanding of printing,’ says Richardson. ‘So when Carter had done all these images and the engravers had engraved nearly all of them, there's a terrible hoo-hah because suddenly they realise the printer can't set the text around the illustrations because there's no room.'

The printer eventually worked out a way to invade the margins, and a scenario that threatened to derail the whole project ended up contributing to its great success.

Gray tried to inflict one final indignity on Carter: diminishing his role in the project. On the proof sheet of the title page of the first edition, there are corrections made in Gray's hand. He indicates that Carter's name should be in much smaller type and moved lower down the page.

'Gray died of smallpox when he was 34, and I think all his papers were destroyed. In those days they used to burn everything when there was an infectious disease in the house. There are no private papers, no diaries, no letters, hardly anything in his handwriting, but I found [the proof sheet] incredibly revealing.'

The type on the proof sheet also says, under Carter's name, 'Professor of Anatomy, Grant College, Bombay'. This was the position he'd gone to in 1858 after he'd finished his studies and the Gray's illustrations. Gray scored a heavy ink line through this, leaving Carter's title only as 'late demonstrator of anatomy at St George's Hospital'.

'If that's all you leave,’ says Richardson, 'it looks as though he's died. It doesn't say “professor of anatomy”, it looks as though he's dead.'

Gray may have metaphorically killed off his illustrator, but it was Gray who met an early death in reality, only three years after the publication of Gray’s. He had little time to enjoy the success of his great book.

'What he did reap was criticism in the national medical press, accused of plagiarism', says Richardson. 'Which I don't think is altogether fair, because anatomy is working on the same text over and over again. The human body is the same text, and the knowledge of anatomy has accrued over centuries from Vesalius onwards, and even Vesalius was using earlier sources.'

'The whole discipline is a palimpsest, so Gray can't be completely blamed for using other people's work. What he was blameworthy for was not giving them credit.’

Gray's Anatomy - a tale of two doctors Sunday 27 July 2014 Listen or download this episode of The Body Sphere to find out more. More This [series episode segment] has image, and transcript

One of the reviews for the first edition makes this clear: 'It gives parallel texts that show that Gray had taken text directly from other sources and had not even said anywhere that he owed anything to anybody else. What upset people about Gray was the arrogance of pretending that it was all his own work. It was really quite shocking.'

If you look at a modern Gray's Anatomy, now in its 40th edition, you'll see a huge list of credits for all the various editors and contributors. It's still got that one name, though, and will forever be associated with an ambitious anatomist and surgeon, even if his 'silent partner' and illustrator deserves some of the credit.

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