This icon of anatomical literature was launched in 1858. Henry Gray was 25 years old when he first conceived of writing a comprehensive anatomy text. Three years later the book was produced. Though Gray's clear prose was a major step forward from contemporary works, its major advantage was the size and quality of the illustrations produced by Henry Carter. He was a contemporary of Gray in St George's Anatomy department but subsequently went to work for the East India Company before the first edition was published. Gray himself saw the success of the first and second edition, only to die shortly after from smallpox in 1861.
The subsequent years have seen many changes in how anatomy is taught—if taught at all. Certainly its key position in undergraduate medical training in the UK has declined along with the number of hours in the syllabus. As a result the public can rest easy in their beds knowing our junior doctors can confidently, competently, and empathically say to the patient they have no idea what their radiograph shows or indeed what structures may have been damaged following a fracture. Inevitably therefore anatomy is becoming a post‐graduate subject, studied by people with a particular area of interest but little overall anatomical knowledge. To meet this need there has been an exponential rise in the number of books, CDs, and internet sites detailing comprehensive or specific anatomical areas of the body.
The 39th Edition of Gray's therefore comes at an opportune time but faces may challenges. In response, the BMJ Editorial group have set out an objective of producing an “Anatomical basis for clinical practice”. The question for this reviewer was, “does it provide an anatomical basis for the Emergency Physician and could I dispense with my Last, Ellis, and Cunningham books?” To answer this I accepted that I would not be able to read it but could consider areas of the book relevant to our speciality from three perspectives:
Does it provide enough information?
Does it provide the information in a comprehensible and memorable fashion?
Does it provide the link between applied anatomy and clinical practice?
Content
The book is now based on seven body systems to best reflect clinical practice. It also makes it easier to navigate the 116 chapters to get to an area of interest. There has also been an update of text, over 800 new illustrations and an increase number of magnetic resonance, computed tomography, and other radiological and operative images used by specialists and generalists. Neuro‐anatomy has been almost completely revised and there has been expansion of the clinical aspects of several areas—for the emergency department doctor the most notably being wrist kinetics, fascial planes of the head and neck, and the temporomandibular joint. The book also comes with a PIN code, which enables the reader to link to a website providing the complete text in an electronic format as well as updates.
Unsurprisingly on reviewing my chosen 15 areas of interest I found the content more than adequate for the practicing emergency clinician and those revising to take the Part A exam. What was unexpected was the number of errors in the text and figures. These vary from the anally retentive—for example, getting the components of the bifurcated ligament the wrong way round (pg 1527)—to clinically important—for example, mislabelling the mitral and tricuspid valves (fig 56.4) and upper limb dermatomes (fig.48.19). It is always easy to criticise and I am aware that a work of this magnitude will have things that will creep under the radar irrespective of the 50 reviewers credited with carrying out this job for the 19 editors.
Comprehensibility
From its first edition, diagrams have been the biggest use in explaining the anatomy. This edition is no exception—some of the figures verge on being works of art as well a clearly providing a clear message. The surface anatomy sections take this one stage further and morph computer generated internal structures onto live human models. The end result is a fascinating series of photographs essential for teaching functional anatomy as well as revising sites for local anaesthesia. Conveniently the textbook comes with two CDs. One has all the figures from the book, which can be down loaded into PowerPoint presentations. The other provides 3D reconstructions of limbs, spine, and heads and neck. These are useful but less sophisticated then other anatomical software available.
Though the line drawings are consistently of a high quality the legends are not. Besides the occasional mislabelling, the arrows sometimes disappear against the background colour leaving the reader lost as to which structure the label is referring to. Several of the radiographs take this to the ultimate level by having black numbers on a black background. One of the lateral radiographs of the ankle and foot (fig 115.10) added to the mystery by having 12 legends but only 11 arrows.
I found the text very different from the narrative style of Last or the sprinkling of historical anecodotes of Ellis. By and large it was plain and unimaginative with only the occasional summary to help the tired reader clarify his thoughts. There is no prioritising of facts or hints on how remember them at 2 am in the resuscitation room. It is therefore a classic reference book. There is nothing wrong with this but it does assume that the reader will be able to understand and retain what is being written because it will not be discussed again. Indeed, I often got the impression it was important to know your anatomy before reading Gray's. Consequently the trigeminal sensory central connections still remains a mystery to me. A further example is found when suppination/pronation are mentioned in the classification of ankle fractures. As these movements had not been previously explained, the uninitiated reader is left trying to work out what it means. If you persist, it is explained en passant seven pages later under the title of “Biomechanics of standing, walking and running”.
Clinical practice
Some of the chapters are obviously written with the clinician in mind. Structures are built up in a comprehensible fashion with frequent references to the clinical usefulness of the anatomical facts being discussed. Of the 15 chapters I read, the knee was good but the spinal cord and basal ganglia were superb. The basal ganglia section was a masterpiece in synthesising anatomical, pathological, and pharmacological text with excellent diagrams. With such good demonstrations I found many lost opportunities—for example, the cerebrovascular supply is comprehensibly covered but is not linked to strokes or computed tomography images; the kinetics of the wrist is discussed but no conclusion or clinical relevance is provided and many conditions and procedures are described but no anatomical figures accompany them. These would have been ideal places to summaries key anatomical features in a comprehensible and memorable way.
Conclusion
My critical review must be taken in the context of a person wanting this anatomical icon to be perfect. It cannot be and it was not. The inclusion of so much new work is bound to lead to new mistakes, which will take time to eliminate. As it stands, it represents a considerable amount of hard work by a huge team of people trying to make anatomy relevant and accessible for the modern clinician. I commend their endeavours and am sure subsequent editions will build on the progress made so far. For now I will use it for its diagrams (especially surface anatomy) and some of its text—for example, spine and basal ganglia—but will still retain my Last for its comprehensible writing and Cunningham for its limb diagrams.