8 Fig.1.7a,b Arabic translation of the works of Galen De Arte Medica (Kităb Galĭnūs fi’t-Tibb) from the Middle Ages. Most of the original works of Galen in Greek have been lost. Those we have were preserved through the Middle Ages by the Arabic transla- tions. The translator was probably Girğis ibn Gibrăĭl, a member of the “House of the Wisdom”, created in 830A.D. in Bagdad by al-Ma’mūn, son of the mythical Califf Hărūn ar Rašĭd. Many of the classic texts were translated in this House. By permission of the Dipartimento per i Beni Archivistici e Librari Biblioteca Riccardiana, Florence mandment Ecclesia abhorret a sanguine, any procedure tion had been kept alive in southern Italy and above all regarded as being unusually cruel, including dissection, in Sicily, which for a long period of time remained un- was strictly prohibited. Scholasticism, the medieval sys- der the influence of the Arabs. According to Bettman tem of theology and philosophy based on Aristotelian and Hench [89] the Scuola Salernitana was founded in logic and the writings of the early Church Fathers, domi- Salerno near Naples sometime around the ninth century nated medical studies as it did all the other branches of by four physicians of different religious faiths: one Greek knowledge. Orthodox, one Jew, one Arab Muslim and one Italian In Italy there was one noteworthy exception to the Catholic. This made it possible for the school to devel- rule that bound the practice of medicine to the religious op unhampered by medieval superstition and above all orders, the famous Scuola Salernitana. The Arab tradi- free from the influence of the Church.8 In this haven the 8 At the Council of Reims in 1131 the Catholic Church prohibited the practice of medicine outside the monasteries. Who knows if this was one of the reasons why Constantine, one of the founders of Western medicine (who brought many medical texts from his native Tunisia to Salerno), abandoned his profession and joined the Benedictine order in the Abbey of Montecassino. CHAPTER 1 The Anatomical Foundations of Surgery 9 practice of surgery flourished, and the school counted such illustrious figures as Roger of Salerno and Rolando of Parma among its teachers. The study of anatomy did not reach such impressive heights, however.9 This seem- ing anomaly can be explained in part by the fact that, de- spite its name, the Scuola Salernitana was a clinic whose principle function was not teaching but the treatment of patients. In 1240 King FrederickII founded the Univer- sity of Naples where dissections were permitted and this contributed to the gradual decline in importance of the Scuola, although it remained in existence until the Na- poleonic era. The Roleofthe EarliestUniversities inthe Teachingof Anatomy During the thirteenth century an important develop- ment took place in the teaching of medicine which until that time, at least in the West, had been, like the arts, based on a direct relationship between teacher and student without the existence of true schools. In reality there had been schools in the past in Mesopotamia and Arabia for the teaching of medicine, but in Europe the Fig.1.8 The first page of Guy de Chauliac’s Chirurgia Magna sole example was the Scuola Salernitana. Eventually in which also contains the writings of the ten most celebrated the thirteenth century, European universities began to surgeons of the time, including Mondeville and Lanfranchi. teach medicine, including anatomy (Fig.1.8). This in- Courtesy of Riccardo Mazzola, M.D., Milan cluded the renowned university of Bologna, which had already been in existence for more than one hundred years. Unlike many of its sister institutions, the studio The founder of the school of anatomy in Bologna was of Bologna had not been founded by ecclesiastic charter Ugo Borgognoni of Lucca (1170–1240), whose work was and its teachers and students were regarded with some continued by his son Theodorico of Cervia (1205–1298). suspicion by the Church. The faculty of law succeeded Theodorico managed to have human dissections includ- in maintaining a considerable degree of independence ed for the first time as an integral part of the medical cur- from the ecclesiastic authorities, becoming completely riculum, even if cadavers were extremely difficult to ob- autonomous in 1306 and this contributed significantly to tain and when available, could only be used for a limited the development of a school of anatomy at the university. period of time due to the lack of means for their preser- In fact, the jurists themselves requested dissections in vation [979]. In the absence of human cadavers, dissec- order to gather evidence for their cases and what began tions were conducted on animals, most often pigs. The as a medical-legal procedure led to increasing scientific advances introduced by Theodorico were consolidated knowledge. by Guglielmo da Saliceto (1215–1276), who described for the first time the motor nerves that govern the con- 9 The earliest surviving documents relating to the Scuola Salernitana date from 848 and concern Giuseppe da Salerno and an- other physician by the name of Josan. The oldest text produced by the school has been attributed to a certain Alfano (1058–1083) and is entitled De Quatuor Humoribus Corporis Humanis (The Four Humours of the Human Body). 10 traction of the voluntary and involuntary muscles [880, 881].10 Taddeo Alderotto of Florence (1223–1303) continued Theodorico’s practices, while his student and successor Henry de Mondeville [682, 731] introduced the use of anatomical diagrams, carefully prepared on the basis of actual dissections, as a teaching instrument. These proved to be an invaluable aid to the students, who could in this way review what they had learned during the faculty’s all too rare anatomy demonstrations.11 Detailed and accurately drawn, these charts were considered by de Mondeville to be absolutely fundamental in the edu- cation of future surgeons. By the end of the 1300s dissections had become an accepted and officially recognized procedure in Bolo- gna, although cadavers remained difficult to come by. This situation favoured the introduction by Mondino de Liucci (1270–1326) innovations which generated sig- nificant impetus and helped transform anatomy into a genuine science [683–685]. Mondino was born, it seems in 1275, to a Florentine family; his father was a pharmacist. He studied medicine in Bologna where Taddeo Alderotti, a fellow Florentine, was teaching and received his degree in 1300. After fur- ther studies under Henry de Mondeville, he became a professor and taught medicine at the university of Bolo- Fig.1.9 The Anatomical Theatre of the University of Bologna gna from 1306 to 1326. During this time he managed to dated 1637. The picture shows the “Baldacchino degli Spel- institute the rule that lessons in anatomy should always lati” (Canopy of the Skinned men) added in 1734. PJS be conducted on the basis of human dissections (Fig.1.9) or when this was not possible, studies on animals, prefer- ably monkeys or pigs. He realized that lectures illustrat- ed with diagrams such as those prepared by his profes- sor Henry de Mondeville were not sufficient. Mondino did not sully his hands personally during the anatomical anatomy would persist until the arrival of Vesalius, who demonstrations; instead he sat in an imposing chair and prided himself on conducting his dissections in person. from there directed an assistant called an ostensor, who Nonetheless, with Mondino’s reforms anatomy was indicated the lines of dissection to a demonstrator who taught more systematically and dissection became the carried out the actual manual labour of cutting the ca- fulcrum of the discipline. Thanks to this Restauratore daver (Fig.1.10). This lofty approach to the teaching of dell’Anatomia, as he was regarded by his contemporaries, 10 Guglielmo da Saliceto’s work Vulgare in Chirurgia contains many sections that are of relevance to plastic surgery. We may cite from BookII his descriptions of treatments for injuries of the nose (chapterIII) and the auricle (chapterVI). Guglielmo was an ad- vocate of the use of the scalpel for surgical procedures in a period when, due to the influence of the Arab school of medicine, cautery was the preferred practice. 11 Henri de Mondeville’s famous anatomical diagrams which he prepared for his lessons as professor at Montpellier, are now conserved at the Bibliotheque Nationale de France. CHAPTER 1 The Anatomical Foundations of Surgery 11 Italy maintained its primacy as the most important cen- tre for anatomical studies until the Renaissance.12 Traditionally the subject of anatomy had been cov- ered in texts on surgery, but in 1316 Mondino wrote Anathomia,13 perhaps the first work exclusively devoted to anatomy. Mondino’s medical principles did not depart radically from those of Galen and the Arab authorities, but his teachings differed in that they were always based upon direct observation and dissections. Since there were no techniques available for the conservation of cadavers, he was obliged to conduct his demonstrations as quickly as possible. Depending upon the season, the longest de- lay he could afford was four days. For this reason his les- sons could not be carried out systematically and organs were examined one by one as they were exposed during the course of the dissection. Nevertheless Mondino did manage to follow a logical sequence and during the dis- section customarily delivered “four lectures on the body. The first concerned the nutritive organs because they were the ones that tended to putrefy the most quickly; second the ‘spiritual’ organs [the head and brain], third the natural organs [for example, the thoracic cavity], and finally the fourth on the extremities and the spinal col- umn” [684, 685]. The cadavers obtained were generally those of exe- cuted criminals, a practice which would continue in Bo- Fig.1.10 Mondino de Liucci (1270–1326) lecturing in Bolo- logna until the sixteenth century. Mondino complained gna. He was the first anatomist to base his lectures on dis- bitterly of the lack of corpses and experimented with sections rather then on diagrams. He did not perform the various solutions to compensate for this dearth of bod- dissection himself but directed the ostensors and demonstra- ies. For example, he developed a procedure for drying tors from a chair. The picture, a woodcut, is taken from Fas- specimens in the sun, an approach that was particularly cicula Medicinae by John de Ketham (fifteenth century Ital- effective for the preservation of tendons, ligaments and ian School). This is probably the first illustrated book dealing bones. Skeletons were obtained by maceration, a practice only with anatomy and the first with colour illustrations. Fon- that would continue for many centuries. Mondino in- dazione Giorgio Cini, Venice, Italy. Archives Charmet – Bridge- troduced many other innovations. He was probably the man Art Library first anatomist to inject coloured liquids into the blood vessels which when solidified, made it possible to study the circulatory system. In his work De Omnibus Huma- nii Corporus Interioribus Membris, printed in 1513, he 12 It was in 1300 and hence during the time of Mondino that Pope BonifaceVIII issued his famous papal bull de Sepoltura which excommunicated anyone who conserved skeletons by boiling their bones. In reality this practice arose for a completely different reason. The remains of persons of rank who died far from home, particularly during the Crusades, were cleaned in this way so that they could be brought home for burial. The papal bull was not directed against anatomists in particular, but could not be ignored by them. 13 Anathomia was published in Padua in 1476 by the printer Pietro Maufer. 12 tion as was still the practice in many other European universities. The professor of anatomy was required to perform two official dissections during the course of the year while his four assistants were responsible for the remainder. Unofficial demonstrations could be held on request at the home of the professor or one of his assis- tants, but for these the students had to furnish their own cadaver and pay an honorarium. It may be said that Mondino’s innovations marked the end of the Pre-Scientific Period and opened the way for the pre-Vesalian Scientific Period, at the end of which we find the masters who were destined to transform the science of anatomy. TheScientific Period BeforeVesalius During the fourteenth and fifteenth centuries many emi- nent figures such as Berengario da Carpi, Alessandro Bene- Fig.1.11 The Archigimnasium of the University of Bologna detti, Leonardo da Vinci and Johannes de Ketham helped was built in 1562. Since 1637 it has housed the Anatomical to lay the foundations for the scientific era of anatomy. Theatre. It was bombed in World WarII.PJS Berengario da Carpi (1460–1530), the son of a well- known Bolognese physician and surgeon, was the first of these. After completing his studies and receiving his degree on 3 August 1489, Berengario held the chair in anatomy and surgery at Bologna from 1502 to 1527. He provides a description of the palate and its role in the was the author of two important works, Isagoge Breves process of speaking. Perlucide in Anatomiam Humana Corpori and Carpi Much of Mondino’s work was inspired by his study Commentarii, in which we find the first description of of the Arab medical literature and many of the terms organs such as the appendix, the thymus, the vas defer- devised by him, such as basilica,cephalica,saphena and ens and the synovia [75–77]. Of particular relevance to retina, reflect this. Certainly the University of Bologna the area of plastic surgery, given their important role in (Fig.1.11) was remarkably advanced for its time, the breast reconstruction today, is his description of the ab- Studio Generale having boldly asserted its right to self- dominal muscles. Furthermore Berengario described the governance and its independence from the Church: “The differences between the male and female pelvis14 with ex- students wanted to practise Medicine without having to cellent illustrations that were probably prepared by Ugo don the cleric’s habit” [89]. Medicine was taught on the da Carpi, a talented painter in Bologna (Fig.1.12a,b). basis of scientific logic, rather than by theoretical deduc- Berengario’s treatise on cranial trauma [74], written after 14 See in Isagoge Breves Perlucide in Anatomian Humani Corpori (published in Bologna in 1522), ChapterII entitled Anatomia Ventris Medii. The same work contains interesting descriptions of the reproductive organs. The illustrations, which were the work of Ugo da Carpi, are noteworthy. CHAPTER 1 The Anatomical Foundations of Surgery 13 Fig.1.12 Diagrams of a the venous circulation of the arm and b abdominal muscles, from the Isogae by Berengario da Carpi. Courtesy of Riccardo Mazzola, M.D., Milan he had treated Lorenzo de’ Medici for a head injury, is rhinoplasty. Other prestigious figures include Giovanni also of interest and we will consider it in more detail in Alfonso Borelli (1608–1679) and Marcello Malpighi our chapter on cranioplasty.15 (1628–1694), but not long afterwards the study of anat- Among the many distinguished anatomists who omy, followed by that of surgery, experienced a decline taught at the University of Bologna was Giulio Cesare in Italy as attention shifted to another area. Indeed, once Aranzid (1628–1694). He conducted pioneering studies the organs of the human body had been identified and on the human fetus and also deserves credit for having their structure determined, it was inevitable that phy- discovered and encouraged the gifted Gaspare Taglia- sicians should begin to ask themselves how they func- cozzi, whom he seems to have taught the procedure of tioned; thus, the study of physiology was born. 15 See De Fractura Calvariae sive Crani, published in Bologna in 1516, where in PartII, ChapterIV the author provides an account of his operation on Lorenzo de’ Medici for a skull fracture caused by a gunshot wound. 14 Fig. 1.13 Portrait of A. Benedetti (1460–1525). Courtesy of the Mayor of Legnago, Verona Fig.1.14 Frontispiece of Alessandro Benedetti’s Anatomia. He designed and started the construction of the famous Anatomical Theatre of the University of Padua. Courtesy of Riccardo Mazzola, M.D., Milan TheUniversityof PaduaBeforeVesalius This development grew out of the general movement known as Humanism, and one of its proponents was During the second half of the fifteenth century Padua, Alessandro Benedetti (1460–1525) (Fig.1.13). Born in like Bologna, experienced a significant revival in the Legnago near Verona, Benedetti attended the university teaching of medicine, which initially took the form of a of Padua and completed his studies in 1475, after which rediscovery of the classical authors and the re-publica- he practised surgery for seventeen years in the Greek ar- tion of their texts in Latin. Editions of the works of Hip- chipelago, where he also mastered the Greek language. pocrates and Galen appeared in 1544 (the works of Cel- In 1490 he was nominated professor of anatomy and sur- sus had already been printed in Florence in 1478), while gery at the university of Padua, and was able to dedicate many other texts were discovered ex novo and interpret- himself to the task of translating some of the most im- ed in the light of the most recent scientific knowledge. portant medical texts from Antiquity. These authorities CHAPTER 1 The Anatomical Foundations of Surgery 15 are amply cited in his Anatomiae sive Historia Corporis Humanis (Fig.1.14), which was published in 1502 [70, 71].16 Benedetti fully embraced the reforms of Mondino and his lessons were always based on direct observation. The author of numerous books, he also designed and began constructing the famous anatomy theatre of Padua (Fig.1.15) whose form was inspired by that of the Roman amphitheatre, in particular the Arena of Ve- rona.17 He became extremely well known and served as the personal physician to many eminent figures in the Republic of Venice, as well as the Emperor MaximilianI of Germany. TheBirthoftheAnatomicalIllustration During the second half of the fifteenth century the prac- tice of human dissection became more widely accepted and spread beyond Padua and Bologna, reaching such a point that even scientists and physicians not directly involved in the teaching of medicine could perform the Fig. 1.15 Anatomical Theatre of Padua. The building was procedure [815]. For example, public dissections were started by Alessandro Benedetti and completed in 1591 by often held in the city of Venice, which did not even have Gerolamo Fabricius ab Aquapendente (1533–1619) (Fig.1.30). a school of medicine. This was the theatre where Vesalius gave his lectures. Univer- During this period a mutually beneficial collabor- sity of Padua, Italy, Giraudon – Bridgeman Art Library ation between artists and anatomists arose. Artists could finally satisfy their curiosity regarding what lay beneath the surface of the living form, while anatomists had their observations recorded in drawings that were both accu- rate and artistic. In this way artists developed an interest Among those who profited from the more liberal in- in the morphology of the human body at a time when tellectual climate was Leonardo da Vinci (1452–1519), the spread of the technique of printing facilitated the dif- who produced anatomical drawings of astonishing accu- fusion of their work. It seems that for a certain period racy and also demonstrated a lively curiosity with regard artists regularly attended dissections. In one of his ac- to the functioning of individual organs, in particular counts Vesalius describes: “… questi pittori e scultori che muscles and bones [550–552]. Born in the Tuscan village svolazzano attorno a me durante le dissezioni” (“these of Vinci in 1452, the illegitimate son of a local nobleman, painters and sculptors who flutter around me during the Leonardo moved to Florence when he was still quite dissections”). young. There he joined the studio of Andrea Verrocchio 16 As we will see in the chapter on nose reconstructions, in Anatomiae sive Historia Corporsi Humanis (VolumeIV, Chapter39,De naso) Benedetti describes a procedure for the reconstruction of the nose almost one hundred years before Tagliacozzi. 17 This famous anatomy theatre was completed by Fabrizio ab Aquapendente in 1591. An exact copy may be seen at the Univer- sity of Uppsala in Sweden—the Gustavianum constructed by Olof Rudbeck in 1622. Rudbeck had studied anatomy in Padua, where he initiated his research on the lymph vessels. Other remarkable anatomy theatres are to be found in Leiden (1596) and Bologna (1637). 16 (1435–1488), a famous Florentine artist who understood sectioned for examination. The modern convention of how important it was for a painter and sculptor to have illustrating the bones in three views, anterior, lateral and a thorough knowledge of anatomy. When he was invited posterior, was introduced by Leonardo. Another field in to Milan by the ruling Sforza family in 1483, Leonardo which he excelled was angiology; in one drawing of the took advantage of the opportunity to conduct dissec- interior of the heart we can recognize such details as the tions at the Ospedale Maggiore, producing five drawings septomarginal trabecula (muscle bundle) of the right of the human skull between 1487 and 1493. He contin- ventricle, which was first described in anatomical texts ued his studies, eventually dissecting the entire human many centuries later. body, and produced his first anatomical work, La Figura If Leonardo’s purpose, at least initially,18 was to es- Umana. When Leonardo left Milan and returned to Flor- tablish an anatomical basis for his paintings, there is ence in 1506, he began collaborating with Marcantonio no doubt that very quickly his scientific curiosity took della Torre (1481–1512) on an anatomy treatise, but this over. Hence his drawings are works of art, but also in- project was interrupted by the premature death of the comparable anatomical studies which were so useful in physician, thus depriving us of what would certainly the teaching of anatomy that it is said even Vesalius was have been a most fascinating work. inspired by his work.19 Leonardo emphasized the importance of the ana- Up until this time the highly inaccurate diagrams tomical drawing in teaching: “How could you describe compiled by the anatomists themselves were copied by this heart in words without having to fill an entire book? scribes who had no specific knowledge of anatomy and In addition, the more details you write on the subject therefore added error to error. For this reason, until the the more you risk confusing the mind of the reader.” fifteenth century when artists began to make their con- Irrefutable support for this argument can be found in tribution, anatomical illustrations were poor. Indeed his meticulous scientific drawings. For the plastic sur- very little had changed since the time of Aristotle, who geon, Leonardo’s two drawings of the palate showing in his Generatione Animalium suggested the use of para- every detail of the musculature of the soft palate (velum digms, schemata and diagrams to illustrate the anatomy palatinum) are of enormous interest, but the quality of of the body. his other studies of the human body can never cease As Louis Choulant [178] wrote, the requirements of to amaze us (Fig.1.16). He completed more than one teaching were best met by: “an ideal human figure based hundred drawings of the heart, lungs, brain, uterus and on the constant use of proportions” and this model was muscles, which are all the more remarkable because we generally followed after Mondino. Choulant divided the know that he conducted his dissections by candlelight. evolution of the anatomical illustration into six stages: With endless inventiveness Leonardo developed various ◉ The period before Berengario da Carpi (1521), when techniques to help him in his studies. For example he in- knowledge of anatomy was still based on schematic jected coloured wax into organs before sectioning them drawings. and this made possible his detailed studies of the cere- ◉ The period from Berengario to Vesalius (1521–1543), bral ventricles. He also constructed wire cages around during which more accurate illustrations, made pos- various joints so that he could study the movement and sible by the technique of woodcut engravings, were function of the muscles. introduced. Leonardo was the first scientist to study the fetal mem- ◉ The period from Vesalius to Casserio (1543–1600), branes. He boiled eyes in albumin so that they could be when the practice of dissection spread and increasing 18 Many famous artists of the period, including Andrea Mantegna (1431–1506) and Luca Signorelli (1445–1523), shared Andrea Verrocchio’s conviction that a knowledge of anatomy could be useful in their work. 19 When Leonardo died his drawings were conserved by his student Francesco Melzi. The son of Melzi sold most of these to the sculptor Pompeo Leoni, who later took them with him to Spain. Two volumes remained there on the sculptor’s death and were only recently rediscovered in the National Library of Madrid. A third volume was sold in 1630 to Lord Thomas Howard, Count of Arun- del and adviser on matters of art to King CharlesI; it is now conserved at the Royal Library of Windsor in England. CHAPTER 1 The Anatomical Foundations of Surgery 17 Fig.1.16 The muscles of the arm, hand and face by Leonardo da Vinci. (RL19012v)The Royal Collection ©2005, Her Majesty Queen ElizabethII numbers of artists began to take an interest in anat- ◉ From Sömmering to the present day. With the intro- omy. The quality of woodcut illustrations improved duction of the technique of lithography, anatomical markedly. illustrations became technically perfect, but their art- ◉ The period from Casserio to Albinus (1627–1737), as istry was lost. anatomical drawings became increasingly accurate and were reproduced in the form of highly artistic In Germany at the end of the fifteenth century, for ex- engravings. ample, modest booklets on medicine were published in ◉ The period from Albinus to Sömmering (1737–1770) the form of almanacs. Der Tierkreiszeichenmann or The witnessed the zenith of the anatomical drawing, Zodiac Man (Fig.1.17) depicted “the different parts of the which was now exact in every detail and meticulously human body which are influenced by different planetary reproduced through the medium of the copperplate conjunctions, [and] indicated the appropriate times for engraving. blood-letting and purging under each sign of the Zodiac,