The eminent mid-20th century British historian of medicine F.N.L. Poynter once said of Gray's Anatomy that "what began as a book has become an institution."

Like all progressive institutions, this one periodically looks itself over, evaluates its development and takes measures to be sure that it has kept up with the times. Keeping up has occasionally required increasing the complexity of its operations, necessarily expanding its bureaucracy, and seeking new and forward-looking leadership. As the institution among medical books, Gray's Anatomy has throughout its history continued to do all these things, with the result that it has only improved with age; it is venerable but not hoary.

With this prologue as background, I am pleased to report that the all-important tradition of improvement with age is most emphatically maintained by the newest edition of Gray's Anatomy, the 39th. The new leadership comes in the accomplished person of Susan Standring, professor of experimental neurobiology at King's College London and incidentally the first female editor in chief. The necessary bureaucracy has been once more expanded to an assemblage of what is by my count a total of almost a score of editors and more than three times that many specialist contributors and reviewers, some of whom are respected holdovers from the excellent 38th edition of 1995. The volume resulting from everyone's labors is, at 11 pounds, now heavy enough for use as a gym weight to build the skeletal muscles it so elegantly describes, from their myoblastic genesis and cellular physiology to their good old-fashioned origins and insertions.

Anyone perusing the last 10 incarnations of this vigorous old warhorse of medical literature will note that a significant change came about with the 35th in 1973, when the visual character of the book began a veritable transformation. Since that time, each edition has incrementally added material covering advances in such fields as molecular biology, imaging, computer-assisted and electron microscopy, embryology and immunohistology to encompass new knowledge and provide didactic clarifications. Henry Gray's original offering of 1858 has taken on the task of providing an overview of the science on which comprehensive understanding of gross anatomy is based in today's biomedical and clinical worlds.

After the publication of the 37th edition in 1989, a formal editorial board was created to provide a supervisory framework for the additions being made by the specialist authors whose contributions were increasing the value of Gray's Anatomy as a source for basic science and clinical applications. When the next edition appeared in 1995, the main changes to be found in it--other than new sections on surface and neonatal anatomy--were organizational, consisting primarily of rearranging the material to make it more accessible and useful. But with the present volume, new and important ground has been broken--or at least more fully and effectively tilled. The authors have increasingly taken on the task of accommodating the new uses to which anatomy is being put in clinical situations, such as minimally invasive surgery, endoscopy, arthroscopy, microsurgery, and the entire expanding field of imaging, including three-dimensional studies.

In addition to providing many pertinent illustrations, Standring and her authoritative team have taken the major and very practical step of presenting their material by regions rather than by the old method of systems such as the reproductive, the gastrointestinal and the muscular. This is a tremendous advantage for clinicians, because it reflects the way in which they need to see anatomy. And it has at least as worthy a benefit for students, because it will correlate even their earliest first-year learning directly to the real world of bedside medicine. Not only that, but brief comments about common diseases are interspersed in the text as their respective anatomical locations are being discussed. All of this is reflected in a change in the book's subtitle, which on first glance would seem insignificant but actually says a great deal. It has gone from The Anatomical Basis of Medicine and Surgery to The Anatomical Basis of Clinical Practice.

Quite obviously, no single reviewer is competent to judge the reliability of every bit of material to be found in this encyclopedic book. As a general surgeon selectively studying sections with which I have a career's worth of experience and only perusing others, I am much taken with their usefulness and lucid readability, which says a great deal for an anatomy text. At the astonishingly low price of $169 for the print edition and only an extra $30 to have it on CD-ROM and online as well, this may be the best value seen in medical publishing since 1819, when Ren Laennec's two-volume treatise on auscultation was put on sale at a price of 13 francs, with a stethoscope thrown in for a small additional cost.

One final word. It is customary when reviewing a book that is in all ways as outstanding as this one to introduce a quibble or two, if for no other reason than to show that the volume has been carefully and completely evaluated with a critical eye. Being a surgeon and not an anatomist (who therefore does not know a fissura antitragohelicina from a sulcus antihelicis transversus), I have been able to find only one item about which to grouse: One looks in vain for the "Surface Anatomy of the Lower Limb" to be found on page 1339, as the table of contents claims. It is to be located 60 pages further on, where the topic is just as clearly presented as is every other facet of this beautifully produced and medically invaluable book.