(1)
Flinders University of South Australia School of Medicine, Adelaide, SA, Australia
Simulation in Anatomy
A simulated patient or body part being used for initial training or subsequent practice needs to look realistic and respond appropriately to inputs and over time. It is important for simulators to have this authenticity for participants to learn the correct behaviors when a particular condition presents. An understanding of how to represent anatomy and physiology was crucial to the development of simulators.
Roman artisans had the skills to craft anatomical simulators, but if they were made it was not for teaching. The Satyricon by Petronius Arbiter (27–66 CE), one of Nero’s courtiers, was a satire on life in Rome. In the book is an account of an elaborate dinner hosted by Trimalchio during which a slave brought a model skeleton made of silver to the table [1]. The joints of the skeleton including the vertebrae were articulated so when it was thrown down on the table it lay bent and contorted. The message was that there was no enjoyment after death and they should eat and drink while they could. Much later, in the eighteenth and nineteenth centuries, devices that reminded of death were popular in Europe but these momento mori, were meant to promote devoutness.
Limitations encountered by all the early anatomists were the availability of bodies and putrefaction. In some cultures and at some times bodies were harder to acquire than others and even if they could be obtained there could be popular resistance to dissection. For example, in the United States, in the second half of the eighteenth century a mob stormed dissecting rooms of the anatomist William Shippen Jr. in Philadelphia and when he fled the scene his carriage was shot at [2]. Before refrigeration and chemical-based techniques of body preservation the decomposition of bodies and body parts was managed by restricting dissection to the coldest months of the year. This gave rise to what became known in Europe and later in the United States as the dissecting season. This was very inconvenient and teachers sought other ways of presenting anatomy to students at other times of the year.
Anatomy and the Renaissance
Claudius Galen (c. 131–c. 201 CE) was a Greek physician who lived in Rome who acquired much of his anatomical knowledge through dissecting non-human primates. Galen extrapolated his findings to humans which was unfortunate because he was given the status of “an indisputable authority” and up to the middle of the sixteenth century most anatomy texts were based on his works [3]. Fortunately the inaccuracies had little impact clinically because very little surgery was performed and only phlebotomists needed much anatomical knowledge for their work and that was only the course of major blood vessels.
There was little dissection performed during the Middle Ages, the statutes of the medical school at Salerno, for example, required a dissection only once every 5 years. Mondino di Luzzi (c. 1270–1326), also known as Mundinus, professor of anatomy in Bologna from 1306 to 1326, began teaching anatomy through regular dissections. To support this activity he wrote the first text on anatomy for students, which was translated and republished several times. Mundinus was supplied with the bodies of executed criminals for teaching but in 1319 four medical students were prosecuted for “body-snatching” which suggests demand exceeded supply [4]. At this time the punishment for some serious crimes was execution but the punishment for the most serious crimes was execution followed by a public dissection.1 For this spectacle a professor of anatomy sat some distance away from the body and read out loud from an anatomical text whilst surgeons and others performed the dissection. Early anatomical texts generally presented the structure of the body in the order of dissection which traditionally started with a vertical incision of the abdomen and removal of the intestines. In a public dissection the professor sat apart from the body and read from an anatomical text whilst a famulus anatomicus made the incisions and an ostensor pointed out the parts [3].
Andreas Vesalius , lecturer in surgery and anatomy in Padua from 1537, broke with tradition and performed the dissection himself [5]. Being so closely involved with the body and teaching meant Vesalius was confronted by the errors Galen had made and he began to correct them. Vesalius was an innovative educator and illustrated his anatomical teaching with large and detailed anatomical diagrams that were called tables. His anatomy demonstrations were popular and in 1538, in response to student demand for his diagrams, he published a set of six broadsides called the Tabulae anatomicae sex.
De Humani Corporis Fabrica Liborum Septem, the most famous work by Vesalius was published in 1543 and in the same year he published De Humani Corporis Fabrica Liborum Epitome which was meant as an introduction to anatomy. Vesalius had taken a great interest in the design and layout of his works to maximize their educational value. He had realized that when the image was cut on a wooden block it could then be set in the frame with the type for the text and be printed together (see Fig. 3.1). This innovation meant explanatory notes on an illustration could be keyed to it on the same page which was a great educational advance [5]. Vesalius depicted many of the bodies in the illustrations as if they were alive and undertaking an activity in a bucolic setting. For example, The skeleton drawn from behind in the Fabrica is drawn standing next to a tree stump with an arm raised as if waving to someone in the distance.
Fig. 3.1
The skeleton drawn from behind by Vesalius. On the scroll, propped against the tree stump, is written: “Printed at Venice by B. Vitali, Venetian, at the expense of Jan Stefan van Calcar. For sale in the shop of D. Bernardus. In the year 1538.” Along the bottom of the sheet are three privileges, from the Pope, the Emperor and the Venetian Senate, prohibiting others from printing or selling these plates (Credit: By permission of University of Glasgow Library, Special Collections)
Vesalius recognized that a drawing on a page was only two-dimensional and could not show the relationships between anatomical structures.
I believe it is not only difficult but entirely futile and impossible to attain an understanding of the parts of the body…from pictures…alone, but no one will deny that they assist very greatly in strengthening the memory in such matters. [6]
Vesalius developed two techniques to help students envision anatomy in three dimensions. First, Vesalius used sequential layering in his books so that the student could start with an intact body and then by turning the pages see the effect of peeling off the skin and musculature to reveal internal organs and ultimately the skeleton. Second, Vesalius used moveable flaps to create a three-dimensional effect of the body and its cavities. He was not the first to use layering but he was the first to use them with very realistic illustrations to show anatomical relationships. De Humani Corporis Fabrica Liborum Epitome was sold with some extra pages on which blood vessels and organs printed and instructions for the purchaser on how to cut out and glue these structures on the base figures to create a layered manikin.
Whilst De Humani Corporis Fabrica is the most famous work on anatomy published in the sixteenth century there were others. Eustachius, both anatomist and papal physician, published the Opuscular Anatomica in 1552 which contained six booklets (libelli) on different parts of the body. The dissected bodies in Opuscular Anatomica were shown in realistic rather than the dramatic poses favored by Vesalius and Eustachius dispensed with scenic backgrounds. Also, instead of keys Eustachius used a grid reference system to identify structures so his illustrations looked clean and uncluttered [7]. After Opuscular Anatomica was published Eustachius began working on an anatomical atlas illustrated with tables engraved on copper, a new technology that allowed finer detail to be shown than could be obtained from woodcuts. Had this atlas been published then, Eustachius would have been remembered with Vesalius [7]. Eustachius did not get to publish his atlas but the plates were eventually published with new captions by Giovanni Maria Lancisi in 1714 [7]. In 1717 another atlas of anatomy based on that work was published by Albinus which greatly influenced Ercole Lelli, Paolo Mascagni and Felice Fontana who made anatomical teaching models in Bologna and Florence (see below).
The first permanent anatomy theater was built in Padova (Padua) Italy for Girolamo Fabrici D’Acquapendente, often referred to as Fabricius, and was inaugurated in 1495 [8]. A surgeon and anatomist, Fabricius held the chair of anatomy in Padua for 50 years [9]. Fabricius had discovered there were valves throughout the venous system and this gave William Harvey the idea of studying blood flow. In 1600 Fabricius published the first work on functional anatomy, De Visione, Voce et Auditu. He was also working on a book on human and animal anatomy and in 1600 already had 300 tables on the largest size of paper available and in color. These Tabulae pictae were lost when Fabricius died but they were discovered in 1907 in a library in Venice [7].
Johannes Vesling succeeded Fabricius and in 1641 he published Syntagma Anatomicum, which became a widely used anatomy text. In De Humani Corporis Fabrica the dissection, even allowing for the inclusion of some allegorical devices, is presented as a chaotic scene. The anatomy theater in Syntagma Anatomicum is an ordered scene with all those present concentrating on the dissection underway.
Vesalius set a new benchmark for quality of artwork in anatomical texts and around 50 years later Johann Remmelin set the standard for flaps in Catoptrum Microcosmicum (Microcosmic mirror) [10]. Published by Remmelin and others2 between 1613 and 1667 this book contained three full page plates with up to 15 successive layers [11]. Eight separate plates were printed for the bookbinder to cut up to make the flaps. It was a popular book with several editions and it was translated from Latin into French, English and Dutch.
In the eighteenth and nineteenth centuries there were several anatomical texts devoted to particular disciplines or parts of the body. These have been included in the sections below. In the last quarter of the eighteenth century a notable anatomical work, or works, that used flaps produced by Gustave Joseph Witkowski (1844–1922) in Paris. This work was published in eight parts between 1876 and 1880 under the series title Anatomie Iconoclasticque and they were also published in English under the series title Human anatomy and physiology [12]. An example of his work, the anatomy of the hand, is shown in Fig. 3.2.
Fig. 3.2
Life-sized hand with several flaps lifted to show muscles, tendons, bones, nerves, etc. From Part 9. A movable atlas showing the bones and muscles of the hand by Gustave Joseph Witkowski [12]
Stereography
“All pictures in which perspective and light and shade are properly managed, have more or less the effect of solidity; but by this instrument that effect is so heightened as to produce an appearance of reality which cheats the senses with its seeming truth.” Oliver Wendell-Holmes (1859) [13].
The invention of photography had a big impact on anatomical teaching but, like drawings, was limited by being a two dimensional representation. In 1838, Charles Wheatstone had described how the slightly different views received by each eye were combined by the brain to create a three-dimensional image. Stereographs, double images presented side-by-side on a flat card looked at in a special viewer called a stereoscope, were displayed to great effect at the Great Exhibition in 1851 where they attracted the interest of Queen Victoria. Stereographs quickly became a global entertainment phenomenon with nearly a quarter of a million stereoscopes sold in London and Paris in just 3 months [14].
In the United States, Oliver Wendell-Holmes invented an inexpensive, a stereoscopic viewer for domestic use. Holmes described how the stereoscopy made objects look as large as they really were, made surfaces look solid and the photographic stereograph made fine detail visible. He wrote most on the pleasure and amusement from looking at stereographs and he advocated libraries of stereographs for professional education [13]. Improved photographic technology in the second half of the nineteenth century simplified the production of stereographs for both entertainment and education.
At the end of the nineteenth century there was increased interest in the educational opportunities of simulating three dimensions. The first stereoscopic atlas of medicine was produced by Albert Ludwig Sigmund Neisser (1855–1916) of Leipzig [15]. The first part of this work was published in 1894 and the last part, the 57th, was published in 1911. Anatomists at the University of Edinburgh produced The Edinburgh Stereoscopic Atlas of Anatomy which was first published in five volumes in 1910 and over time was expanded to ten volumes that included 324 stereograms [16]. There was also an Edinburgh Stereoscopic Atlas of Obstetrics that had 100 stereoscopic views.
A Stereoscopic Atlas of the Eye by Arthur Thomson published in 1912 included 67 “enlarged stereoscopic photographs” of human eyeballs in various states of development and dissection [17]. Stereoscopic Studies: Pathological Anatomy of the Eye, which had 64 stereographs, was published by the Imperial Publishing Co. of New York in 1914 [16]. A stereoscopic atlas of eye diseases by Karl Wessely (1874–1953), then Director of the Munich University eye clinic, was published in color in four parts between 1930 and 1931. The notes on each image were in French and English as well as German [18]. Albert E. Bulson Jr. claimed the Stereoscopic atlas was “as faithful a representation of the principal operations on the eyeball, as can be had apart from their actual performance on the human subject.” A System of Ophthalmic Operations published in 1911 included a chapter by Albert E. Bulson Jr. on “The Development of Operative Skill by the Surgeon” [19].
The Medical Art Publishing Co. of New York produced An atlas of diseases of the Skin in 1914 in a box that contained 132 color stereographs of skin diseases such as pellagra, eczema, dermatitis and syphilis with detailed notes and a Holmes-type viewer with a metal hood. Hand-held viewers, however, exposed the stereographs to the risk of accidental damage and table top cabinet viewers that could hold sets of stereographs with accompanying notes were developed (see Fig. 3.3). Sets of stereographs could be loaded in the cabinet and then individual views were changed using a handle on the side of the instrument avoiding the need for students to handle them. After the Second World War an updated stereographic atlas of anatomy was produced on View-Master reels. This technology has been superseded by computer-based displays that are usually viewed through special glasses or on 3-D screens. Some of the earlier stereographs have been digitized and can be seen this way.
Fig. 3.3
Stereoscopic viewer (Credit: University of Dundee)
Anatomical Models
Ivory Miniatures
Many small anatomical manikins, models of dissected bodies, were carved from ivory3 in the seventeenth and eighteenth centuries [20]. These 10–20 cm long models were of males and females, often in pairs, shown lying on ornate bed and contained in a wooden box (see Fig. 3.4). Typically the chest and abdominal wall could be removed to show the major organs. The intestines could be removed to show the bladder in the models of males and a uterus containing a fetus in models of females. Sometimes the fetus was attached to the uterus by a red silk cord and could be removed.
Fig. 3.4
Ivory anatomical manikin (Credit: Dittrick Medical History Center, Case Western Reserve University)
The anatomical detail of these models varied greatly and it was thought inadequate for teaching health professionals until a note written in old French in 1786 was found in the case of one of the manikins. This text was translated by Thompson,
In Life’s full bloom, when labor’s toil so near
My fellow sufferers’ lot and perils I do fear,
Come ye fair pupils, Lo, I cast aside my shame
That Midwif’ries secrets may reveal my frame.
Pierce it with keen enquiring eye, and may
The child and mother’s nature then convey
New manifold devices to your skillful art
That pining women may not henceforth smart
Through cruel untaught efforts, and not gasp
With their unborn in Death’s unpitying grasp.
Written by Joseph Fuardi de Fossau, Professor at Verceil during the vacations of 1786, who had been struck by the extreme ignorance of those persons who practiced midwifery and the bad effects which often ensued from it…. He was ashamed that his pupils in surgery should not be better taught, and he constructed this figure for the purpose described in the above lines [20].
Wax Models
During the middle ages it was thought that much illness was punishment for wrong doing and believers would pray to be kept from harm or cured. To extend the reach of prayers it became popular from the fourteenth century to offer “acts of devotion” in places of worship generally and specifically before religious artifacts associated with miraculous powers to seek a grace (propitiatory ex voto) such as fertility or relief from pain, or to give thanks for a grace (gratulatory ex voto) such as surviving an illness or injury. The votives were typically organs or body parts that could be represented as healthy or diseased but the wealthy would commission life-size figures of themselves. The skills and technology to make these wax models were developed to create copies of anatomical dissections.
The works of Vesalius created interest in anatomy and attending public dissections became popular. In Europe and Great Britain the dissecting season was limited to the coolest months of the year. In Bologna public dissections were integrated in calendar of the winter carnival. Anatomists wanted to be able to study and teach on cadavers all year but the preservation techniques available in the seventeenth century only slowed putrefaction. It was discovered that tubular structures and cavities could be preserved as replicas by injecting them with wax but the resulting models were very fragile.
In 1599 an Italian artist and architect called Lodovico Cardi (1563–1613), also known as Cigoli and Civoli, made a small ecorchè (flayed man) in red wax. This 61 cm tall statuette was the first accurate wax anatomical model and was variously called “Anatomia del Cigoli” (Cigoli’s anatomy), “La bella notomia” and “lo scorticato” (the skinned man). Casts of this figure in bronze and plaster were very popular and it was widely copied. In 1691 Cosimo III de Medici employed the artist Gaetano Giulio Zumbo (or Zummo) who was known for his spiritual or religious works. Zumbo experimented with different colored waxes and created four small but highly realistic tableaux portraying disease and death. The works had titles like “The Plague” and “The Triumph of Time” and were known collectively as the “Theaters of Death.” It was said that the depiction of decaying flesh and the destruction of the body was so meticulous in the tableaux that just looking at them “will evoke a sense of overwhelming stench” [21]. In 1695 Zumbo began collaborating with the surgeon-anatomist Guillaume Desnoues and produced the first polychromatic wax models of dissections which were then exhibited and sold. Zumbo later moved to Paris where he collaborated with other surgeon-anatomists which helped spread the technique of anatomical modelling in wax outside Italy [21].
In Bologna a permanent anatomy theater large enough for public dissections was created in the Palazzo dell’Archiginnasio, the main university building. The oldest permanent anatomy theater still standing is in Padua and the smallest is in Pistoia but the anatomy theater in Bologna is the most ornate. Between 1732 and 1734, Ercole Lelli carved two large “scorticati” from umbrella pine that were placed either side of the professor’s chair in the anatomy theater [7, 22]. In 1742 cardinal Prospero Lambertini established an anatomy museum at the university and employed Lelli to make the first collection of wax models specifically for teaching anatomy [7]. Lelli produced several dissections in wax and eight life-sized models showing the body being progressively dissected as they appeared in the drawings in Tabulae Anatomicae by Eustachius published in 1714. Lelli was joined in Bologna by the husband and wife wax modellers Giovanni Manzolini (1700–1755) and Anna Morandi4 (1716–1774) who produced many superbly detailed anatomical waxes particularly of the sensory organs, the viscera and the female pelvis. Normal and abnormal anatomy was captured in the new medium such as models of a normal and a horseshoe kidney. These models were far more durable than the preparations they were copied from and many can still be seen today. They could also be duplicated and some copies were sent to other locations in Italy and exported across Europe.
Giovanni Battista Morgagni (1682–1771) began his medical studies in Bologna and was appointed Professor of Anatomy in Padua in 1712. Morgagni made careful notes on nearly 700 autopsies he performed and studied the relationships between a patient’s symptoms and signs and the post-mortem findings. The result was De Sedibus et Causis Morborum, the Sites and Causes of Disease, which was published in 1761 and created the field of pathological anatomy. It also created a role for pathology museums.
The wax anatomical modelling studio that became known as “La Specola” (the Observatory) was established in Florence by Felix Fontana in 1771. In 1773 Clemente Susini (1754–1814) began working at the studio and over the next 40 years produced more than 2000 models in wax. He is best known for making extremely realistic, life-size models of young women with parts that could be removed to reveal deeper layers in a similar way to the flaps in some anatomy books (see Fig. 3.5). The colorings of the models make them look more alive than dead and the sheets they lie on have not a drop of blood.
Fig. 3.5
The Veneria Clemente Susini—wax statue of a young woman lying (Credit: Museo di Palazzo Poggi—Universita di Bologna, photo by Fulvio Simoni)
Susini typically worked directly from cadavers and often made moulds from them so it is thought his models are exact copies of his subject [23]. In a model of a young pregnant woman there is a congenital heart defect and some features that would be consistent with this. It is quite possible that this was the cause of death of the woman dissected for the model although many models were composites of a number of dissections [24].
Italian wax models, particularly from Florence, were exported around the world for professional collections for teaching and for public exhibition. There is a particularly good collection of models by Susini at the University of Cagliari in Sardinia, Italy. Francesco Antonio Boi, the professor of anatomy at Cagliari had acquired the wax models which he had seen whilst on a sabbatical tour of anatomy teaching centers on the Italian mainland [25].
More than a thousand of the Florentine models were purchased by Emperor Joseph II of Austria on the advice of the surgeon Giovanni Alessandro Brambilla (1728–1800). The models were housed in the Josephsakademie, a new military surgico-medical academy now often referred to as the Josephinium. Unfortunately, and partly for political reasons, the medical elite dismissed them as toys and expensive luxuries and as result no professional was prepared to use them [26].
Across Europe, anatomical models were exhibited to the public from the middle of the eighteenth to the middle of nineteenth centuries. Over this time London was home to several private “for-profit” collections and their development and eventual demise has been documented. Initially it was proposed that these exhibitions were to further educate the cultured mind but the need for visitors meant they were increasingly promoted for curiosity and awe. Typically the cost of entry to the exhibition included instruction on anatomy or a related topic and a guided tour. In Beauties, Harmonies, and Sublimities of Nature published in 1837, Charles Bucke (1781–1846) described a visit to an anatomy museum in London [27].
A short time since we went to see an anatomical figure of a female, said to be (externally) modelled from the Venus de Medicis, by Signor Serantoni, of Florence. The exhibitor took off the skin; and we perceived veins, arteries, and nerves. Then he took of other coverings, and we beheld … the centre of the internal structure; including a full grown child in the womb. Then he unmasked the face … The head was then taken to pieces, and we saw the cavity of the brain, the brain itself, and all the interior parts of the head.
In the nineteenth century the term Florentine began to be used to describe the style of a model rather than its origin and some later “Florentine” models were not as well made as those originating in Florence [24]. In Italy men and women viewed the anatomical models together but this would have been scandalous in Britain so times were reserved for viewing by ladies led by a woman.
Entrepreneurial surgeons and man-midwives (obstetricians) in the eighteenth century had preserved specimens, created anatomical preparations, and made apparatus to assist their teaching which was private. When the man-midwife Colin Mackenzie died in 1775 his collection was purchased by colleagues who wanted to continue the successful school of midwifery he had established. In the nineteenth century, medical and surgical education was increasingly provided in public hospitals and associated teaching institution and most private collections of physicians and surgeons were transferred to them. When John Hunter died his extensive collection was purchased by the British Government and presented to the body that became the College of Surgeons [28].
A few collections, such as Kahn’s Museum of Anatomy and Pathology remained in private hands. Joseph Kahn (b. 1820) was a German physician who had toured Europe with a collection of anatomical, surgical and embryological specimens preserved in alcohol and models made of wax and leather, before settling in London in 1851. Kahn intended his museum “to present the scientific observer with a general and correct view of the perfect and wonderful structure of the body” [29]. The museum itself was not a financial success but Khan found a way to profitability through a business venture with Perry & Co, who offered cures for venereal diseases. Visitors to the museum who recognized the signs of infection portrayed in wax in themselves could see a “doctor” on the spot. The museum became the first walk-in venereal disease clinic but unfortunately the treatments offered weren’t effective.
The Obscene Publications Act (1857) was used to force Kahn’s museum to close in 1873. It was claimed the exhibits encouraged unmarried persons to “gratify their passions without the consequences which follow,” namely pregnancy and venereal disease which was “conduct inconsistent with public morals.” Many of Kahn’s models were destroyed by court order and the remaining private anatomy museums closed soon afterwards. Apparently, women and the lower classes were most prone to corruption from seeing anatomical preparations, pictures and models but the superior qualities of medical professionals, who were male and middle-class, meant they were immune from the corrupting influence.
In France, Biheron was a highly regarded medical model-maker who developed a reputation for creating very realistic “artificial anatomies.” Some of the models made by Biheron moved realistically and were used to demonstrate processes such as childbirth as well as anatomy. These models are described in the section on obstetric simulation in France.
In the United Kingdom, the most notable anatomical model-maker was Joseph Towne (1806–1879) who worked at Guy’s Hospital in London in the middle of the nineteenth century. Towne was originally appointed by Sir Astley Cooper and worked closely with the anatomist and surgeon John Hilton to produce several hundred extremely realistic wax anatomical models. The Italian wax models were life-like but like today’s air-brushed cover models, they had no blemishes. Towne’s models were exact copies of dissected corpses and had warts, comedones and bad teeth.
Wooden Anatomical Models
Napoleon Bonaparte was most impressed by the anatomical works he saw in Italy and commissioned many works for use in health professional education in France. One of these was a life-size figure of a standing man made by Felice Fontana (1730–1805) that had 3000 wooden parts. The model was very detailed (see Fig. 3.6) and could be converted to a female body but was extremely laborious to make and expensive [30]. Unfortunately, although the wooden parts were more durable than wax and could be handled by students, changes in humidity made them warp which affected how well they fitted together.
Fig. 3.6
Details of the head and neck of an anatomy mannequin made by Felice Fontana in the early nineteenth century. This model on display in the Musée d’Histoire de la Medicin of the Université Paris Descartes was ordered by Napoleon Bonaparte
Caspar Wistar, professor of anatomy in Philadelphia at the end of the eighteenth and beginning of the nineteenth century also used wooden models in his teaching. Wistars anatomy lectures were very popular and he was concerned that in very large classes he could not demonstrate the structure of small parts of the body to them all at once [31]. Wistar’s solution was wooden models on a very large scale prepared by a Mr Rush described as “the most celebrated carver of his time in Philadelphia.” The first models were of the sphenoid, palate, and ethmoidal bones, the temporal bone, and the labyrinth of the ear, as well as of the brain in sections and every year he added to the collection. John Syng Dorsey, Wistar’s successor, suggested “No one could fail to become an anatomist who diligently attended his lectures.”
Carton Simulators
Jean-Baptiste Philippe Nicolas René Laumonier (1749–1818) was a surgeon in Rouen who at the end of the eighteenth century began making wax models to teach anatomy. The models were very good and in 1807 Napoleon established a School of Artificial Anatomy in Rouen directed by Laumonier to supply models to the Schools of Health in France. These models were very useful but they could not be handled or taken apart for students to learn the relationships between structures [32].
Ameline
Around 1808, the surgeon Jean François Améline (1763–1835) professor of anatomy at the medical school in Caen, France, began making anatomical models from a range of materials including papier-mâché. The first models made by Améline, which he showed at a meeting of the medical society in Caen in February 1817, were of a hand and a head [33]. The muscles were made of papier-mâché and blood vessels and nerves were represented by colored yarn and silk thread. A review of the models published in the Health Gazette thought the models were particularly suited for demonstrations in the amphitheater.
Two years later Améline presented several artificial anatomical models including an arm, leg, head and a full figure representing a standing man standing to the Royal Academy of Science in Paris. The surgeons Portal and Percy reviewed Ameline’s models, which they referred to as fantôme d’anatomie [34]. Whilst they reported the anatomical simulator would be very useful for young anatomists, they concluded “we cannot for a moment, admit that it should be considered of paramount importance as a means of instruction, or that it is possible to become an anatomist by the aid of this phantom of anatomy” [35].
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