Under the Skin: the evolution of Gray’s Anatomy

Gray’s Anatomy is one of the most influential illustrated books in the world. In print since 1858 it has gone through 41 editions, evolving alongside our knowledge of the human body. While artist Henry Vandyke Carter’s role in its conception has been eclipsed by his more celebrated co-author, it is his pioneering work that shapes how the book exists today.

The 41st edition of Gray’s Anatomy: The Anatomical Basis of Clinical Practice runs to nearly 1,600 pages and is about two and a half inches thick. The index alone is 108 pages long and the entire volume contains, says its publisher Elsevier, the result of “building on over 150 years of anatomical excellence”.

But while it’s a formidable object, it’s far from being one that is set in stone. Since 1858, when Henry Gray and Henry Vandyke Carter first published their book in London, it has evolved alongside medicine itself; its words and pictures reflecting current knowledge to ensure that it remains an up-to-date resource for students and practitioners all over the world.

Published in a new edition roughly every five years, the current Gray’s Anatomy in fact contains little of the 19th century original: both Gray’s words and Carter’s drawings have been updated several times in the intervening years. In 2008, when the book marked its 150th year in print, the milestone was celebrated by completing the renovation work started by editor-in-chief Dr Susan Standring when she first took on the job in 2004.

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‘Muscles of the Head, Face and Neck’ by Henry Vandyke Carter, from Gray’s Anatomy; John W. Parker and Son, London, 1858. Image courtesy, Elsevier. Image at top of post: ‘Surgical Anatomy of the Arteries of the neck. Right side’ by Henry Vandyke Carter, from Gray’s Anatomy; John W. Parker and Son, London, 1858. Wellcome Library, London

All artwork was revised or replaced under the art direction of Richard Tibbitts of UK studio Antbits, the number of colour illustrations was increased to 2,000, while new diagnostic and clinical imagery was added “to capture anatomy the way it is seen in practice”. The 41st edition came out last September and contains photography, X-ray, CT, MR and ultrasonic images alongside illustration. Gray’s Anatomy now also boasts an eBook and online component that extends its range of imagery, video content and commentary.

While the Elsevier edition is both authoritative and up-to-date, it’s not the only version you can buy. The Running Press offers an unabridged facsimile of the 1901 volume and Barnes & Noble’s Leatherbound Classics version is based on the 15th edition of the book, featuring a handsome cover by Jo Obarowski and Mada Design. In the hand, this feels more like a gift for an aspiring doctor than a working textbook – both volumes contain very small type alongside the drawings that were used at the time.

Yet the Barnes & Noble edition goes some way to demonstrate the wider significance of this unique publication, particularly to those outside of the world of medicine. For many, as an illustrated book it is both a cultural and a scientific artefact. “It is a work of Art!” reads one of the Classics edition’s several five-star reviews on Amazon.

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‘Dissection of the upper extremity of an arm, actual size, showing the nerve affected by Leprosy’ (1862) by Henry Vandyke Carter, from On leprosy and Elephantiasis; George Edward Eyre and William Spottiswoode, London, 1874. Wellcome Library, London

Gray’s Anatomy: Descriptive and Surgical (the book’s original title) was the work of two young medical teachers working in mid-Victorian London. Gray, an anatomist and surgeon, and Carter, a surgeon-apothecary and artist, met at the Kinnerton Street school attached to St George’s Hospital and laboured in its dissection rooms to create the text and images that would go into the former’s idea for a new student textbook. But while Gray’s surname would feature on the spine of the book, Carter’s name was left off the cover, his contribution listed only on its title page – and, at the insistence of his co-author, who oversaw and made corrections to the final proofs, his name was to be displayed in a smaller typeface, further separating word from image.

This incident is retold in Dr Ruth Richardson’s The Making of Mr Gray’s Anatomy and she has done much to re-establish Carter’s role within the story of the book – and right his injustice. Opening her chapter on Carter, Richardson writes: “There are a good many curious things about Gray’s Anatomy, not the least of them being that although the book’s famous selling point has always been its illustrations, the name of the man who drew them is hardly known.”

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‘Left superior maxillary bone. Outer surface’ illustration by Henry Vandyke Carter from the first edition of Gray’s Anatomy, 1858. Image courtesy, Elsevier

At the time, the illustrations Carter produced for the book were remarkable. Reviews lauded their clarity of line, thanks in part to the talents of the engraving firm, Butterworth and Heath, with the British Medical Journal observing that the book was “far superior to all other treatises on anatomy” and that “the woodcuts … are excellent – so clear and large that there is never any doubt as to what is intended to be represented”.

Richardson claims the success of Carter’s work lies in its pared down, rational, almost technical precision; a revival of a much older tradition which eschewed the more extravagant practices of drawing anatomical forms that appeared in the 18th century.

As Richard Barnett writes in The Sick Rose: Disease and the Art of Medical Illustration, these books were often “grand affairs: oversized and exquisitely bound, printed on fine paper and published in editions of a few hundred, mostly for subscribers”. Beautiful, yes, but not very practical. By the early 19th century, however, publishers had thought to produce works on a mass scale for the student market, creating something more like “a piece of field kit – a map, perhaps, trusted and used to destruction in the bloody business at hand”.

In this way, Carter’s drawings were, he adds, “closer in spirit to an engineering blueprint than a painterly still life”. And in looking to the future they also evoked “the kind of mechanical objectivity that by the end of the century would come to be associated with scientific photography. Perhaps this is the key to their endurance,” Barnett concludes, “these images gesture towards past and future, while evoking so keenly the atmosphere of their time.” As Barnett hints at, Carter’s illustrations also made use of contemporary mapping techniques – the labelling of the images is, where possible, on the drawing itself rather than relegated to a key.

For Richardson, too, Carter’s images were drawn acts of concision, which aligned with Gray’s clear prose. “The book is a sort of anatomical ‘look and say’,” she writes. “One of the most distinctive qualities in Carter’s illustrations is that they look and say all on their own. They are definitely visual, but also verbal.” Carter’s artworks seemed to lay out the body helping to bring forth Gray’s descriptions: “showing behind, above, below, concave, smooth, passes through, arises from, and lies along; and at the same time telling trapezius, clavicle, sternum, hyoid, sterno-thyroid”.

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‘Oblique section of the articulations of the tarsus and metatarsus. Shewing the six synovial membranes’ illustration by Henry Vandyke Carter from the first edition of Gray’s Anatomy, 1858. Image courtesy, Elsevier

Anatomy is aptly described by Richardson in an interview as “an accreted discipline”, so just as the writing in Gray’s Anatomy absorbed and mirrored the understandings of the day, so too did the visuals reflect the latest in image-making technology.

After Gray’s untimely death from smallpox in 1861, aged just 34 and a year after the book’s second edition, Timothy Holmes became its editor for the next seven editions, before passing its stewardship on to Pickering Pick, who in 1883 introduced colour printing to the publication for the very first time. In 1905, Robert Howden took over and, having seen the book go through numerous illustrative approaches, decided to go back to specially commissioned line drawings and wood engravings.

Later, TB Johnson formally renamed the book as ‘Gray’s Anatomy’ before bringing X-ray plates to its pages in 1938 and electron micrographs in 1958. Since then, Richardson writes, “the book has grown in size, and has become less a student work than a major work of reference, an indispensable encylopaedia of anatomy, whose illustrations are extraordinarily various, colourful, and informative”.

In 1973, Gray’s underwent a major revision – a third of the illustrations were recommissioned – and was reset as a two-column page design. Standring’s opening salvo with the 2004 edition was to reorganise and update its content again and move it online prior to her complete renovation in the 2008 edition. Last year’s offering embraced the best of what well-designed print can do but also recognised the role that interactive and motion graphics can play in helping to convey complex structures and processes. The preface to the 41st edition acknowledges how Gray’s Anatomy’s digital components have considerably altered the way its illustrations can be viewed.

Richard Tibbitts, the medical illustrator and co-founder of the Antbits studio which now creates the vast majority of the illustrations in Gray’s Anatomy, believes Carter’s work has indeed been overshadowed by his colleague’s name.

“In the US, medical artists such as Frank Netter and Max Brodel are seen as demi-gods of medical illustration,” he says. “Carter’s work can be seen as simplistic, but for me truly marks the beginning of medical illustration as [the] visual communication of complex text as opposed to [a] visual documentation of observed anatomical dissections which had come before.”

Tibbitts has had a long relationship with Gray’s Anatomy and, for the 41st edition, led a team of 13 other illustrators with his Antbits partner, Paul Richardson. His ascent has been interesting. In 2001, the studio was given the opportunity to work on some material for a new student edition of the book that Elsevier were planning – impressed with the team’s work, they were invited to oversee the production of imagery for the main publication, alongside its eBook.

Exploded skull by Antbits, as featured in the current edition of Gray’s Atlas of Anatomy
Exploded skull by Antbits, as featured in the current edition of Gray’s Atlas of Anatomy

“We were approached to produce some samples for this new text but told not to go to too much length as we would certainly not get the deal,” Tibbitts recalls, “as the main editorial team were based in the US, where medical illustration is far more recognised as a profession, and there are umpteen medical illustration studios, some of which had also been approached. I took the advice, but secretly was hell bent on getting the gig. I reviewed all the previous editions of Gray’s and was highly influenced by the early illustrations done in the 1970s by ‘REMM’ and the tonal works of AK Maxwell.

“I was fascinated in the simplicity and diagrammatic approach that was taken to convey the anatomy,” Tibbitts adds. “They were more medical information graphics than illustrative representations of dissected specimens. This is also evident in Henry Carter’s original woodcuts, due to the limits of the reproduction techniques of the time, the illustrations were highly diagrammatic. I wanted to hold this at the core of our samples and knew this would set us apart from the US studios as they still had a very traditional approach – even if computer-generated, they replicated traditional methods of pen and ink and wash.”

A new artwork created for the 41st edition of Gray’s Anatomy by Antbits, showing the inner workings of the hand
Figure showing the radial side of the hand, from the current edition of Gray’s Anatomy, courtesy of Rolfe Birch from his book Surgical Disorders of the Peripheral Nerve. Design: Antbits

Antbits’ approach resonated with a large focus group of first and second year medical students and the team began work on Gray’s Anatomy for Students soon after. “This I undertook solely with Paul Richardson as we were too precious about diluting the approach,” Tibbitts explains. “It was a fantastic opportunity to illustrate a complete anatomical text book from scratch and the authors Rick Drake, Wayne Vogl and Adam Mitchell were so up for the new illustrative approach and we formed a great bond working together which made the end result more than just a commission.”

This work naturally brought their efforts to the attention of the editorial team behind the main Gray’s Anatomy and they were invited to handle a small amount of new artwork for the 39th edition of 2004 and began a greater overhaul of the illustrations for the 150th anniversary text, making use of their full team of illustrators.

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‘Figure of the vasculature of the uveal tract’, from the latest edition of Gray’s Anatomy, with permission from Hogan et al, The Histology of the Human Eye, Saunders, 1977. Design: Antbits

“I art directed all of the new anatomical works and the colourisation of the existing tonal work, illustrating as much as I could myself,” says Tibbitts – who delights in maintaining a hands-on involvement with the work – while the physiology and embryology sections were handled by two other artists, Ethan Danielson and Robert Britton. “There are not a lot of us in the UK but other talented medical illustrators contributed work and updated previous editions such as Philip Wilson who was my head tutor at university and the man responsible for guiding me down the medical illustration path, as all I wanted to do then was draw the inside of animals and dinosaurs!”

Tibbitts has since been offered the authorship of another Gray’s-related title, Gray’s Atlas of Anatomy, the companion to the student text, which is now on its third edition, while also furthering Gray’s ventures into apps.

Since first working on computer graphics in the mid-1990s, Tibbitts acknowledges the significance of working on Gray’s Anatomy today. “For me, having chosen a career in medical illustration it is the holy grail of medical texts,” he says, “and to be offered the opportunity to become the latest Gray’s artist is something I do not take for granted.” Tibbitts may be using different tools to those available to Carter in the late 1850s, but the focus of his work – to further understand the human body – remains the same as 150 years ago.

The 41st edition of Gray’s Anatomy is published by Elsevier (£150), elsevierhealth.co.uk. More of Antbits’ work at antbits.com. This article appears in the current edition of CR – our ‘health’ special, subscribe.creativereview.co.uk

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