Anatomist’s View of Artistic Works

Abstract

Nine episodes about works of art were collected from the perspective of an anatomist-physician.

1.1 Adam’s Apple and Airway Obstruction

I enjoy action movies like the James Bond (007) series, because many famous landmarks are filmed in them. The title of the 14th film in the 007 series was “A View to a Kill” (1985, starring Roger Moore). While watching this movie, I enjoyed the depiction of several places in France, especially the Château de Chantilly. This castle has a very beautiful garden and the Musée Condé.

Among the many collections of the museum, a drawing in a book intrigued me. A naked man is holding his neck with both hands. He seems to be suffering from asphyxia. A naked woman with an apple in her right hand is looking at him. Between the man and woman, a snake is slithering up a tree. The name of the book is Abstract of the Bible, Revelation (Chantilly, Condé Museum, 0028, printed in 1378) (Fig. 1.1).

Fig. 1.1

Abstract of the Bible, Revelation. Adam suffers from asphyxia caused by eating a piece of an apple

This drawing was made very early, in 1378, well before the publication of Milton’s Paradise Lost in 1667, which reads:

Of man’s first disobedience, and the fruit

Of that forbidden tree, whose mortal taste

Brought death into the world, and all our woe,

With loss of Eden, till one greater man

Restore us, and regain the blissful seat,

Sing Heav’nly Muse…

Among the many paintings of Adam and Eve, this one is unique, because it expresses the suffering face of Adam as he experiences asphyxia caused by eating an apple. This leads to an intriguing question: why do people believe that the fruit was an apple and use the term “Adam’s apple” for the thyroid cartilage? In Genesis 3:5, Vulgate, Satan says, “You will be like God, knowing good and evil (Eritis sicut Deus, scientes bonum et malum).” The Latin word malum has several meanings: evil, disaster, and apple. It seems that in this context, malum was understood as an apple.

As trauma surgeons, we frequently encounter patients who suffer from airway obstructions, like Adam in the above-described picture, especially in cases of facial injuries.

Airway obstruction due to a foreign body often can be easily treated; if the foreign body is removed, the patency of the airway can be restored. Airway obstruction caused by trauma, however, may lead to hypoxic brain damage. In acute upper airway obstruction, an evaluation should be conducted immediately. The necessary airway equipment should be made available at the time of evaluation.

In trauma patients, since the tongue has fallen backwards toward the posterior pharynx and blocks the airway, we can lift the tongue and clear the airway by hyperextending the head and pulling up the chin. Additionally, gentle pressure behind the jaw lifts the mandible and maintains airway patency. If this maneuver cannot restore the airway, tracheostomy should be performed following the relevant guidelines, especially in children [1].

In trauma patients, airway management is challenging beyond the placement of an endotracheal tube, and the outcomes depend upon the provider’s ability to anticipate difficulty [2]. Among the types of facial trauma, panfacial fractures are caused by high-energy trauma and potentially result in upper airway obstruction, which needs a rapid diagnosis to save the patient’s life [3].

With appropriate training, percutaneous cricothyrotomy can be easily performed as part of prehospital care [4]. Recently, four cases of prehospital surgical airway cannulation on the battlefield demonstrated three successful uses of prehospital cricothyrotomy kits [5].

As known, in cricothyrotomy, a limited skin incision is made to the cricothyroid membrane between the thyroid and cricoid cartilages, in the midline just beneath the Adam’s apple. Thus, Adam—the founding father of humanity, as portrayed in the Bible—gave us a landmark to maintain the airway!

1.2 Toe Deformity of a Gilt-Bronze Pensive Bodhisattva Statue

I recently visited the National Museum of Korea, where I viewed two pensive Bodhisattvas in the Room of Quiet Contemplation. Among the two gilt-bronze statues, one was familiar to me, since I previously wrote about Bodhisattvas’ face, which has a hint of a smile that exhibits a sense of serene concentration and gives the viewer the impression of an aura of deep thought [6]. In Buddhism, any person who is on the path toward Buddhahood (the condition and rank of a Buddha, awakened one) is called a “Bodhisattva.” This time I focused on the cross-leg sitting and bare right foot, where I observed hyperextension of the first metatarsophalangeal joint and flexion of the interphalangeal joint of the pensive Bodhisattva (National Treasure 83, Fig. 1.2).

Fig. 1.2

Pensive Bodhisattva (Korean National Treasure 83). Note the hyperextension of the first metatarsophalangeal joint and flexion of the interphalangeal joint of the hallux

It is well-known that Siddhartha Gautama (Buddha, c. sixth to fifth century BC or c. fifth to fourth century BC) founded Buddhism. Before the expedition of Alexander the Great (356–323 BC) to the East, people in eastern Asia thought that transcendent beings like God could not be expressed as human figures. Thereafter, Buddhists did not make any statues of the Buddha; instead, they made stupas, which contained small crystals believed to be derived from Buddha’s cremated remains. There was an approximately 500-year period when the Buddha was not represented as a figure. Later, as the Greek culture was transmitted to the East, the first statue of Buddha appeared in the Gandhara region. The resulting statues were influenced by ancient Greeks’ pursuit of ideal beauty, which they perceived as arising from harmony and balance.

Buddhism was transferred to China through the Silk Road in the first century AD and then to the Three Kingdoms of Korea in the fourth to sixth century AD. The above-described pensive Bodhisattva statue was produced in the late sixth century in Shilla Kingdom.

This statue (National Treasure #83) of the pensive Bodhisattva differs from the classic contemplative pose with one leg perched up on the other knee and the fingers of one hand raised against the cheek. This pose is derived from the image of the young Indian Prince Siddhartha Gautama contemplating the nature of human life, which is quite common in Buddhist sculpture. In China, such pensive statues were most widespread in the fifth and sixth centuries, but in Korea, they were most frequently produced in the sixth and seventh centuries.

In both Korea and Japan, however, the pensive Bodhisattva is generally considered to depict the Maitreya Bodhisattva (known as the future Buddha). This iconography is thought to reflect the Sutra on the Descent of Maitreya, in which the Maitreya follows a similar path in life as that of Prince Siddhartha.

Normally, it is impossible to hyperextend the first metatarsophalangeal joint and flex the first interphalangeal joint with the remaining toes in neutral position. In a close look, a shallow groove can be seen on the medial border of the big toe and metatarsophalangeal joint. The statue definitely shows a deformity of the right big toe, known as the hallux hammertoe (hallux malleus) or claw toe.

A question then arises regarding why the artist who made this statue (600–650 AD) made a “deformed” toe in a sacred statue of the future Buddha. A likely interpretation is that the model for the statue, who was believed to be a Buddhist nun or monk, had that deformity. Then, we may ask—why did that Buddhist nun or monk have a toe deformity?

A recent article could provide an answer to this question. A cross-sectional survey was conducted in combination with foot and ankle examinations of monks living in northern Thailand. In the 208 monks who were included, common foot and ankle problems were callosity (70.8%), toe deformities (18.2%), plantar fasciitis (13.4%), metatarsalgia (3.8%), and numbness (2.9%). Commonly found toe deformities included hallux valgus and claw toe. Hallux valgus was found in 14.4% of Thai monks and claw toe in 4.3%. The reasons for monks’ foot deformities are as follows:

• 1. Thai monks usually walk without wearing shoes for long periods of time each day, causing increased pressure on the plantar surface of the foot. The push-off and heel-strike phases during barefoot walking create high pressure on the forefoot and heel, respectively.

• 2. Monks walk in rural areas that do not have smooth surfaces or on concrete or dirt roads. High contact pressure on the plantar aspect of the foot results in callosity.

• 3. Monks cease wearing shoes when they are ordained. Prior to that, their feet usually have not been accustomed to barefoot walking. Callosity and toe deformities were associated with prolonged barefoot walking over extended periods since ordainment (P < 0.05) [7].

Based on this article, we infer that the early seventh-century Buddhist monks, who practiced strict asceticism, walked barefoot like the Theravada monks in present-day Thailand (Fig. 1.3). Through the enigmatic smile, we also can conjecture that the Buddhist monks were happy and “awakened” despite their foot deformity caused by their barefoot training.

Fig. 1.3

Buddhist monks, who practiced strict asceticism, walked barefoot. This type of walking causes foot deformity (hallux hammertoe or claw toe)

These deformities can now be improved by surgery. If the hallux hammertoe or claw toe is flexible, a tendon release may be helpful. If the deformity is rigid, joint fusion or arthroplasty may be needed to straighten the big toe.

1.3 Symbol of the Physician in “St. Luke Painting the Virgin”

According to the Golden Legend (1260), written by Blessed Jacobus de Varagine (1230–1299), Emperor Nero persecuted Christians in the aftermath of the Great Fire of Rome (AD 64). Paul, as their main leader, was arrested, tried, and condemned to death, and he awaited execution in a prison cell. Luke took a risk by visiting Paul, and in his prison cell, Luke wrote down a narrative of the conversions they performed and their missionary travels together. This text would become the “Acts of the Apostles.” This narrative eventually provided encouragement to Christians in the face of possible martyrdom [8].

St. Luke, one of the four evangelists (Matthew, Mark, Luke, and John) is venerated as the patron saint of artists, physicians, bachelors, surgeons, students and butchers. His original profession was a doctor (a surgeon, as well as a physician). He was one of the first doctors of the Christian era. His symbol as an evangelist is an ox since his gospel (Gospel of St. Luke) emphasizes the priestly and sacrificial work of Jesus. The ox represents the sacrificial aspect of Jesus’ ministry. Some paintings represent St. Luke as an artist painting the Virgin Mary and child (Fig. 1.4).

Fig. 1.4

“St. Luke Painting the Virgin” (1550–1553) drawn by Maerten van Heemskerck (1498–1574). (From public domain through https://commons.wikimedia.org/wiki/File:Maarten_van_Heemskerck_-_St_Luke_Painting_the_Virgin_-_WGA11320.jpg. Assessed 29 Jan 2022)

We are then faced with the question: what is the symbol of St. Luke as the patron saint of physicians and surgeons?

To answer this question, I searched some literature and art from the Renaissance period and found a relevant painting.

Maerten van Heemskerck (1498–1574) created a painting called “St. Luke Painting the Virgin,” which is believed to have been made during 1550–1553.

In this piece, St. Luke is painting a panel supported on his lap, while other figures in the background are occupied with tasks in the artist’s studio. A sculptor is putting the finishing touches on a recumbent stone figure; in the gallery in the top left, a number of people are working around a table, and the courtyard contains several pieces of sculpture. The ox and the thick volume of an opened book without letters, on which the ox is resting his foot, are definitely symbols of St. Luke as an Evangelist. The empty book will be filled and become the Gospel of Luke. In the painting, Luke is making final touches of portraits of the Virgin and the child. It is notable that the child has masculine figures. The child’s forearm muscles, thigh muscles, and leg muscles are exaggerated like those of an athlete. Below the ox’s leg is a glass urinal, which was used as a tool for urinalysis in that era.

In the lower right corner, a large book is open and facing the viewer. The left page, which is numbered I76, contains a text in Greek. The illustration on the right page has four figures: two human skeletons, a male nude viewed from behind, and a male figure viewed from the front, whose body appears to have been opened by frontal dissection.

According to art historians, the Greek letters are recognized as “De anatomicis administrationibus” (“On Anatomical Procedures,” compiled by Galen) [9]. The alternation of the skeleton and “muscle man,” with the two left-hand figures viewed from in front and the right-hand figures from behind, suggests that Heemskerck must have been acquainted with this engraving, which resembles the illustrations in Vesalius (1514–1564) drawn by Jan van Calcar (1499–1546). Giorgio Vasari, Carel van Mander, and others credit Jan van Calcar with the 11 large woodcut illustrations of anatomical studies that accompanied Andreas Vesalius’s work on anatomy. The most notable of these works is the anatomical study of the human body entitled “De humani corporis fabrica libri septem” or “On the Fabric of the Human Body in Seven Books” (1543) [10].

“De humani corporis fabrica” (1543) was published just 10 years before the completion of this painting (1550–1553). In the painting, the book with Galen’s guide to anatomy on one page and illustrations based on Vesalius on the other is opened towards the viewer. In fact, Galen dissected animals but never dissected a human body. It is thought that Heemskerck intended to use Galen’s authority and Vesalius’ new knowledge of anatomy as the symbol of the “ideal doctor” in that era.

In the Renaissance, anatomical science served as an important source of inspiration for artists. Interest in anatomy had become relatively widespread by the fifteenth century, during which artists dissected cadavers. The artists aimed to create accurate portrayals of facial expressions, positions, reflexive motions, and draped clothing. Artists’ expertise primarily derives from their observations of living subjects. Instead, dissection provides a fixed model without flowing blood, which cannot be used as an animated model. Nonetheless, these artists likely learned about the anatomical origins of vivid expressions by studying the muscles lying under the skin [11].

In the present day, there are many hospitals and medical centers named after St. Luke. Moreover, numerous Christian medical doctors have “Luke” as their baptismal name. They took this name from the patron saint with the same name. What, then, will be the symbol of the ideal physician in our age?

As exemplified by the book with Galen’s guide to anatomy and illustrations based on Vesalius, doctors will gain knowledge, skill, and appropriate attitudes by reviewing the old (Galen, in the painting discussed above) and learning the new (Vesalius). These will be their symbol of “authority” as good doctors.

1.4 “The Flying Eye” of a Renaissance Artist: An Anatomical View

The human eye can conjugate and focus on both near and distant objects. Conjugation requires good function of the levator palpebrae superioris, as well as the extraocular muscles or ciliary muscle. Through conjugation, artists use the law of perspective, which started in Renaissance period. The first scientific study of this phenomenon was contained in De Pictura (On Painting, published in 1450), written by Leon Battista Alberti (1404–1472) (Fig. 1.5). In his book Ludi Rerum Mathematicarum (Mathematical Pastimes, 1450–1452), he illustrated methods of measuring the natural and built environment in the perspective framework.

Fig. 1.5

Alberti’s drawing showing the vanishing point

Alberti used the flying eye (winged eye) as his personal emblem. In Matteo de’ Pasti’s medallion (c. 1446–1450), the profile is on the obverse and the eye on the reverse. At the top of the eye is a pair of eagle’s wings, and emanating from each corner are rays. Below is the motto “Quid Turn,” meaning “What then?” or “What next?” and surrounding it, a laurel wreath (Fig. 1.6).

Fig. 1.6

Emblem of Alberti; the flying eye (winged eye). (Matteo de’ Pasti, National Gallery of Art, Washington, D.C. Samuel H. Kress Collection)

An Italian architect wrote that Alberti borrowed the Egyptian Horus eye, which symbolizes exactly this tireless exploration that continues even after earthly life. She interpreted the winged eye, surrounded by a bay necklace and adorned with wings, as representing an afterlife journey toward the knowledge of the true essence of nature [12].

As an anatomist, I have different opinion. In the Renaissance, anatomical science was a major source of inspiration for artists. In the period after Anathomia (1316) by Mundinus and before Fabrica (1543) by Vesalius, artists as well as anatomists dissected human cadavers. By the fifteenth century, interest had emerged in anatomy, and the artists of the period dissected cadavers. Some had a good knowledge of anatomy and applied anatomical knowledge of features, such as muscle shape and volume in their works.

Alberti, one of the geniuses of the fifteenth century, is also thought to have had extensive anatomical knowledge. In a close observation of Alberti’s flying eye, I could see the anatomical structures represented in it. The upper and lower lid margins, as well as the tarsal plates, are carved. Medially, the medial palpebral ligament (medial canthal tendon) is attached to the medial orbital rim [13]. Laterally, the lateral palpebral ligament (lateral canthal tendon) is attached to the lateral orbital rim [14]. In the lateral view, the two wings attached to the upper tarsal plate seem to represent the eye-opening muscles: the levator palpebrae superioris and Muller’s involuntary muscle [15, 16]. In the lower eyelid, the oblique stripes seem to be the capsulopalpebral fascia and arcuate expansion [17].

Artists sought to accurately portray facial expressions, positions, reflexive motions, and draped clothing. Observation of living subjects is the primary source of artists’ expertise. Dissection provides a fixed model without flowing blood, which cannot be used as an animated model. It is thought that the artists of that era learned about the origins of vivid expressions from the anatomy of the muscles lying beneath the skin.

The emblem of “the flying eye” is therefore, I believe, a symbol of Alberti’s profound anatomical knowledge of the human visual organ, which lay at the root of his conception of “the law of perspective.”

1.5 The Missing Nose of the Virgin Mary

A man paints with his brains and not with his hands.—Michelangelo Buonarroti

I recently visited St Peter’s Basilica in Vatican City, where I saw the familiar “The Pietà” (The Pity, 1498–1499) made by Michelangelo Buonarroti (1475–1564). It was located just on the right side of the entrance. Since this sculpture was protected by a very thick glass panel, I could only see a frontal view.

The reason for this protection is the damage done by a mentally disturbed geologist in 1972. With blows from the geologist’s hammer, the Virgin Mary’s elbow, one eyelid, and the most strikingly, her nose were broken (Fig. 1.7, left). Some pieces were recovered, but Mary’s nose was not, and it had to be reconstructed from a block cut out of her back (Fig. 1.7, right).

Fig. 1.7

The head of the Virgin Mary. Left: damaged (1972). Right: reconstructed from a block cut out of her back (1973)

I observed the Virgin Mary’s restored nose with an opera glass that I carried and noted that she had nostrils, but they were very shallow, and it looked as if she only had nostril pits.

This famous work of art depicts the body of Jesus on the lap of his mother Mary after the Crucifixion. Anatomically, the nose has a three-dimensional contour with skin that covers it, a middle layer of bone and cartilage support, and an inner mucosal lining. Nasal defects require three-layer reconstruction, including resurfacing with forehead tissue; support with a septal, ear, or rib graft; and replacement of the missing lining. I prefer a scalp flap or a medial forehead flap.

When sculpting marble, it is not easy to create airways in the nose. However, it would have been possible to create airways from the nostrils to the nasal valve when restoring the missing nose. I thought that the restorer took liberties to restore it in a way that was more “rhetorical” and less “anatomical.”

If the restorer had precise three-dimensional anatomical knowledge of the facial structure, the Virgin Mary would have gotten a new nose through which she could have exhaled onto her dead son.

It would be mutually beneficial if plastic surgeons and artists shared their knowledge and viewpoints.

1.6 Skinned St. Bartholomew Before (1541) and After (1556, 1562) Fabrica (1543)

In the Renaissance, anatomical science was a major source of inspiration for artists. By the fifteenth century, interest had emerged in anatomy as an area of research, and the artists of the period dissected cadavers.

Artists performed dissections in order to pursue divine beauty, in the belief that God created humankind in his image, whereas anatomists’ goal was to gain scientific knowledge [18].

It is well known that St. Bartholomew was portrayed dressed holding a book and a knife up until the thirteenth to fourteenth centuries, alluding to the Gospel that he proclaimed and the martyrdom that he suffered.

From the Renaissance onward, the iconography of St. Bartholomew with his skin removed from his flesh was finally sanctified after Michelangelo (1541) portrayed him in such a way in the “Last Judgment” in the Vatican’s Sistine Chapel. It is notable that St. Bartholomew holds his skin in his left hand. However, he himself is not skinned at all but covered with normal skin. Thereafter, the muscle underneath the skin is visualized as surface anatomy only. However, in the “Last Judgment,” he holds extra skin in his hand (Fig. 1.8 upper left).

Fig. 1.8

St. Bartholomew depicted in “Last Judgment” (1541. upper left), and statues of Marco d’Agrate (lower left: bronze, 1556, lower right: marble, 1562). Dissected body in Fabrica (1543, upper right)

Two years after the completion of the “Last Judgment,” Andreas Vesalius published his Fabrica (De humani corporis fabrica libri septem, 1543, Fig. 1.8 upper right).

Subsequently, 13 and 19 years after the publication of Fabrica, Marco d’Agrate made a bronze statue of St. Bartholomew in 1556, in front of the Certosa of Pavia (1556, Fig. 1.8 lower left), and a marble statue in the Milano Duomo (1562, Fig. 1.8 lower right), respectively.

These works of Marco d’Agrate do not show any psychological introspection or give evidence of the deep faith expressed by the martyrdom of St. Bartholomew. However, they form part of a major sixteenth-century sphere of interest: the study and presentation of human anatomy [19].

By comparing the portrayal of St. Bartholomew in Michelangelo’s fresco and d’Agrate’s statues, we can see the how the publication of Fabrica contributed to art. Artists and anatomists together produced images of the body that combined medical knowledge and an artistic vision. When illustrated anatomical texts became readily available in the seventeenth century, the general enthusiasm of artists for studying cadavers decreased.

1.7 The Cut Surface of the Neck as Depicted in Two Paintings of Judith and Holofernes

In the Renaissance, anatomical science was a major source of inspiration for artists. By the fifteenth century, interest had emerged in anatomy as an area of research and the artists of the period dissected cadavers. Artists performed dissections in order to reproduce beauty accurately, whereas the anatomists’ goal was to gain scientific knowledge [18]. Artists witnessed or participated in dissections to gain a better understanding of the proportions and systems of the body.

Although detailed treatises on human proportion and beauty were published by artists and scholars such as Albrecht Dürer, the cut surface of the human body is rarely found in paintings.

The aim of this paper was to compare the cut surface of the neck depicted in two paintings of Judith and Holofernes.

Two paintings, Judith with the Head of Holofernes (Lucas Cranach, 1530, Jagdschloss Grunewald, Berlin) and Judith in the Tent of Holofernes (Johann Liss, 1628, National Gallery, London), were analyzed.

In the Bible, Judith 13:8–9 tells the story of a beautiful Jewish widow, Judith, who saves her people by murdering the Assyrian general, Holofernes. She tricks him into trusting her, but when he is drunk, she cuts off his head.

In Cranach’s Judith, Holofernes’ head is bearded and his dead eyes roll upward; the muscles and other anatomical structures in his neck are made available for our inspection. The cut surface of the neck is shown from underneath. The cervical vertebra and trachea are clearly shown. The sternocleidomastoid, trapezius, and other neck muscles are discernible. However, bleeding from the vessels is not portrayed (Fig. 1.9).

Fig. 1.9

Judith with the Head of Holofernes (Lucas Cranach, 1530, Jagdschloss Grunewald, Berlin)

In Liss’ Judith, Judith has cut off the head of Holofernes and looks back over her shoulder, toward the viewer. She is placing the severed head in a basket. The cut surface of the neck is shown from above. The cervical vertebra and trachea are identifiable, and blood is pumping from the carotid arteries. The muscles are discernible due to the blood (Fig. 1.10).

Fig. 1.10

Judith in the Tent of Holofernes (Johann Liss, 1628, National Gallery, London)

Mondino de Luzzi wrote Anathomia corporis humani in 1316. This book is considered the first example of a modern dissection manual and the first true anatomical text and remained the most widely used anatomical text for 250 years (through the sixteenth century).

Lucas Cranach (1472–1553) and Johann Liss (1597–1631) were both born in Germany.

Cranach’s Judith (1530) was painted 5 years before Anatomia Carpi (1535), by Jacopo Berengario da Carpi, and 13 years before De humani corporis fabrica (On the Fabric of the Human Body), by Andreas Vesalius. It is an interesting coincidence that this Fabrica and the famous De Revolutionibus Orbium Caelestium by Nicolaus Copernicus were published in the same year (1543).

Liss’ Judith (1628) was painted in the same year that William Harvey published De Motu Cordis (Fig. 1.11).

Fig. 1.11

The chronology of famous anatomy publications and the two Judith paintings

Comparing Cranach’s Judith (1530) and Liss’ Judith (1628), the latter portrays hemodynamics as well as topographical and cross-sectional anatomy. It therefore appears that over the course of one century (1530–1628), artists’ anatomical and physiological knowledge improved.

For many artists in the Renaissance, to be an artist was to be an anatomist. As artists turned toward more lifelike portrayals of the human body, they needed a deeper understanding of how the structures of the body worked together.

Artists and anatomists together produced images of the body that combined medical knowledge and an artistic vision [20]. The artists aimed to reproduce the exact surface anatomy of the human body, but the sectional depiction was very rare, and they also requested a good knowledge of the “deep” anatomy.” Now, five centuries later, the main depiction of anatomy through medical imaging uses sections (CT, MRI) [21].

1.8 War Horse, Whistlejacket, and an Anatomist

During my stay in London, I had a chance to enjoy “War Horse,” played at the New London Theatre located in the West End. This famous play is the story of a young boy and his beloved horse, which has been requisitioned by the army to fight in World War I. The life-sized puppet was manipulated by three puppeteers—the Head, the Heart, and the Hind—who worked together to make the character of the horse come alive on stage. The puppet was made in Cape Town, South Africa, of cane, leather, and synthetic fiber, and an aluminum-reinforced spine. With life-like accuracy, the puppeteer operators articulated the limbs of the horse and communicated its emotions (Fig. 1.12).

Fig. 1.12

War Horse and 3 puppeteers. (Reproduced with permission from Victoria and Albert Museum, London)

I was so impressed, since the skeleton and joints of the limbs as well as the spine were anatomically very similar to a real horse. In order to achieve this life-like effect, the skilled craftsmen who constructed this incredible puppet had anatomical knowledge of horses.

For detailing equine anatomy, Carlo Ruini’s Anatomia del Cavallo (1618) [22] was a first, foundational text, followed by Andrew Snape’s The Anatomy of an Horse (1683) [23]. George Stubbs published the illustrated book The Anatomy of the Horse (1766), which is still in print today (Fig. 1.13) [24].

Fig. 1.13

Skeleton with reference plate from The Anatomy of the Horse (1766). (Reproduced with permission from The British Museum, London)

Stubbs dissected horses to learn about their anatomy for his illustrations and paintings. He rented a farmhouse for study and dissection. The horses were sacrificed by cutting the jugular vein, and the blood vessels were injected with tallow. The carcass was lifted with a tackle of hooks and bars attached to the ceiling; the horse’s feet were arranged on a wooden plank beneath. He removed the skin, prepared the muscles layer by layer toward the skeleton, and sketched them [25, 26].

In the National Gallery, I saw a very famous oil painting entitled “Whistlejacket” (1762) by Stubbs. The pose was typical of an equestrian portrait, although without the rider. This horse has a dynamic personality and glowing vitality (Fig. 1.14). It is obvious that Stubbs could paint horses in realistic detail, because he had great knowledge of their anatomy. He could see the muscles, bones, and joints under the skin and their actions from the sketches he made during dissections.

Fig. 1.14

Whistlejacket (1762) (oil on canvas) by George Stubbs. (Reproduced with permission from National Gallery, London)

As a plastic surgeon and a teacher in resident training program, I considered the role of anatomy for surgeons and surgical trainees. On reading the top-cited paper in the first 25 years’ history of Clinical Anatomy, I realized the importance of anatomical dissection cannot be overemphasized in medical education. In that paper, 57% of the residency program directors responded that residents need a refresher in gross anatomy upon arrival, 29% thought that they were adequately prepared, whereas 14% felt they were seriously lacking. The residency programs indicated that residents need to arrive more proficient in clinical applications, general knowledge, and cross-sectional applications [27]. I was worried that about half of the anatomy departments are not consisted of training teachers of anatomy (gross anatomy, histology, embryology, and neuroanatomy) [28].

The gross anatomy is no longer a free-standing course representing anatomy-for-anatomy’s-sake but rather is now strongly clinically oriented in many schools [29].

Artists need knowledge of anatomy for painting animals or human beings in realistic detail, and surgeons need precise understanding of anatomical details for successful operations. Stubbs could see the horse muscles and their actions during his dissections, and so too can surgeons recognize the critical structures, such as vessels or nerves through anatomical knowledge obtained from surgery or dissection.

Though there are many texts and atlases showing surgical and radiological anatomies for students and trainees, I do believe nothing can replace the anatomical dissection.

1.9 The Human Premaxilla and Goethe

It is safe to say that most plastic surgeons are familiar with the growth pattern of the premaxilla in bilateral cleft lip and palate patients, in whom in utero growth of the premaxilla is excessive and directed more horizontally, resulting in a protrusive premaxilla at birth [30]. Despite the common usage of the name of this bone, the origin of its nomenclature is not widely known to many plastic surgeons. I have carried out a review of publications about the premaxilla.

When Galen (131–201) was active, the premaxilla had already been observed in animals. Coiter (1573) was the first anatomist to describe this medial part of the upper jaw as a separate bone in the vertebrate skull. He also illustrated the incisive suture (sutura incisiva) in humans [31].

In the eighteenth century, Petrus Camper from Holland stated that a vitally important anatomical difference between humans and animals was the missing intermaxillary bone (premaxilla) in man, with this being the distinguishing feature between humans and monkeys. Contradicting this theory, Goethe (1749–1832) found the intermaxillary bone in the human skull in 1784 [32]. Goethe hoped to present this discovery through his friend Johann Merck, who was in contact with Camper and could serve as an intermediary. However, Merck delayed forwarding the manuscript and also did not forward Camper’s eventual replies. Thirty-six years later, in 1820, Goethe submitted his hypothesis, but it was rejected by the leading anatomists of the time.

Last year, I visited Leipzig for research collaboration. In Leipzig, I saw the statue of Goethe (Goethedenkmal), which reminded me of the name of a pub (Auerbachs Keller) that appears in his Faust, which is set in that city. The Korean researcher accompanying me led me to the tavern and said that Goethe (1749–1832) was a regular at Auerbachs Keller as a university student from 1765 to 1768.

I saw the statues of Faust and Mephistopheles at the gate of that tavern. I also viewed a wall painting depicting the last scene of Faust. In the first edition of Faust, I observed that the midface and upper lips of Mephistopheles and Martha were retracted and the lower lip protruded like that of a cleft palate patient (Fig. 1.15).

Fig. 1.15

Mephistopheles (upper) and Martha (lower) in the first edition of Faust (1808)

It is therefore possible that Goethe’s discovery of the premaxilla in humans, which he did not succeed in publishing, was reflected in the painting of Mephistopheles and Martha, who were portrayed with the retracted maxilla that is seen in cleft palate patients and elderly people who are losing their maxillary teeth.