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International Journal of Cardiology

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Review

Illustration of the heart and blood vessels in medieval times

Majid Khalili a, Mohammadali M. Shoja a,b,c,, R. Shane Tubbs d, Marios Loukas e, Farid Alakbarli f, Andrew J. Newman g
a

Tuberculosis and Lung Disease Research Center, Tabriz Medial University, Tabriz, Iran Clarian Neurological Institute, Indianapolis Neurosurgical Group (ING), United States Indiana University Department of Neurosurgery, Indianapolis, IN, United States d Section of Pediatric Neurosurgery, Children's Hospital, Birmingham, AL, United States e Department of Anatomical Sciences, St. George's University, Grenada f Institute of Manuscripts of the Azerbaijan National Academy of Sciences, Baku, Azerbaijan g Department of Islamic and Middle Eastern Studies, the University of Edinburgh, United Kingdom
b c

a r t i c l e

i n f o

a b s t r a c t
Throughout history, illustrations had played a key role in the promotion and evolution of medicine by providing a medium for transmission of scientic observations. Due to religious prohibitions, color drawings of the human body did not appear in medieval Persia and during the Islamic Golden Age. This tradition, however, has been overlooked with the publication of the rst color atlas and text of human anatomy, Tashrihi Mansuri (Mansur's Anatomy), by Mansur ibn Ilyas in the fourteenth century AD. Written in Persian and containing several vivid illustrations of the human body, this book gained widespread attention by both scholars and lay persons. In this article, a brief history of Mansur's Anatomy and an English translation of selected sections from this book regarding the heart and blood vessels are presented. 2009 Elsevier Ireland Ltd. All rights reserved.

Article history: Received 12 November 2009 Accepted 30 November 2009 Available online xxxx Keywords: Anatomy Heart Illustration Medieval Persian

1. Introduction The Mongol invasion of Persia, which took place in the thirteenth century AD was one of the most disastrous events in the history of Persia; many crucial cities like Gundishapur, Nishapur, Merve and Ray with large libraries and educational centers were destroyed by the invading Mongols ruled by Changiz Khan [1]. Later, the Mongols conquered Baghdad with eventual collapse of the last Islamic caliphate, the Abbasids [2]. Following the collapse of the Islamic Caliphate, three powers rised in the region and were based in Persia, Turkey and Egypt [3]. Persia was ruled by Mongols (Ilkhanid dynasty) [3] who in contrast to their predecessors became patrons of science and medicine [1]. In this era, a large educational complex, the Rabi Rashidi, was built and had the primary goal of training students in medicine and pharmacology. The library of the Rabi Rashidi contained over 60,000 books [4]. Enhanced by several pharmacies and hospitals, Rabi Rashidi became a multinational university where students and physicians from China, Syria, Egypt, India, Mesopotamia and other countries as well as Persia began training, teaching and practice [4,5]. Remains of the Rabi Rashidi may still be seen in Tabriz in northwestern Iran.

In the decades following the dissolution of the Ilkhanids, another illustrious contribution to medicine was made with the publication of Mansur's Anatomy, the rst color atlas of human anatomy [2,6]. This book, written by the well-known physician Mansur ibn Ilyas, was copied and widely distributed among both laypersons and scholars. Publication of Mansur's Anatomy is now regarded as a turning point in the history of medicine in Persia and the Islamic world as a color atlas of the human body was until that time prohibited under prior Islamic regulations [7]. Of course, the use of paintings and drawings was not unique to this text, and in fact, the examples of this revolutionary production can be observed in earlier manuscripts of the Ilkhanid era such as the Jami al-Tawarikh (Compendium of Chronicles) of Rashid al-Din Fazlollah Hamadani (12471318), the wise grand minister of the Ilkhanid court and founder of the Rabi Rashidi [8]. In this paper, a brief history of Mansur's Anatomy and an English translation of selected sections from this book regarding the heart and blood vessels are presented.

2. Mansur ibn Ilyas and his Tashrihi Badani Insan (Anatomy of the Human Body) Mansur, whose full name was Mansur ibn Mohammad ibn Ahmad ibn Yousef ibn Ilyas, was born to an afuent and well-respected family in the city of Shiraz in the central Persian province of Fars in the middle of the 14th century AD [9,10]. His clan consisted of generations

Corresponding author. Clarian Neurological Institute, Indianapolis Neurosurgical Group (ING), United States. E-mail address: shoja.m@gmail.com (M.M. Shoja). 0167-5273/$ see front matter 2009 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ijcard.2009.11.061

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of physicians who were also active as jurists and poets, and were well known for their gnosticism and literature [9,10]. Mansur was a descendant of Najm al-Din Mahmud ibn Ilyas who was appointed by Rashid ad-Din Fazlollah Hamadani as the chief of a hospital in Zanjan in the southeast of Tabriz [7,10]. Mahmud was a knowledgeable physician, jurist and author of a medical compendium (Kitab al-Havi Ilm al-Tadavi or Comprehensive Book on Medicine); his text was based on his experiences from traveling to other eastern countries [11,12]. Mansur was trained by family members [13] and by attending traditional schools in Fars and by visiting other cities including Tabriz. His visits to Tabriz probably enriched his knowledge due to the rich scientic background that existed following the establishment of the Rabi Rashidi. Mansur authored several medical texts including the Kifaya-yi Mansuri, a synopsis of general medicine [14], and the Tashrihi Badani Insan or Tashrihi al-Abdan (known as Tashrihi Mansuri), a systembased anatomy text with color illustrations [10]. The Kifaya was dedicated to Sultan Mujahid al-Din Zein al-Abedin Shah Shoja, the last Muzaffarid ruler of Fars before the conquest of the Timurids [14]. Compiled in 1386, Mansur also dedicated his anatomy textbook to Prince Pir Mohammad Bahador, the grandson of Tamerlane [1315]. Mansur's Anatomy was written in Persian and in a systems-based approach composed of an introduction on the body parts with remarks from Aristotle, Hippocrates, Galen, Rhazes, Avicenna and prophetic tradition. This was followed by ve articles on the bones, nerves, muscles, veins and arteries, and a concluding chapter on the complex organs and fetal development [2,10]. Mansur's Anatomy received great attention in Europe [16]. The following is the authors' translation of selected sections from a recent edition and annotated, Persian version of Mansur's Anatomy [10]. 3. Selected translations from Mansur's Anatomy Introduction. Though Aristotle's assertion that the heart is the rst to develop was from observation and deduction, for those who perform dissection, observation is superior and better than deduction. Semen contains many airy elements and corporeal heat too, and the rst thing derived from it is the essence of spirit because its development is easier, and its demand is high. Hence, the essence of spirit is formed and collected rst. As the spirit is a owing existence, from the viewpoint of physicians, it does not stand by itself. So, it requires a receptacle to keep it from being wasted. This receptacle should have its motion and direction to [both] sides. Therefore, it must be located in the center and at an equal distance from the sides (note a statement was not translated here because its meaning was unclear to the translator). The heart is the structure that surrounds the spirit. Hence, the rst organ, which is developed and acts as the receptacle of spirit, is the heart (pages 3940). The fth article: On the arteries (Fig. 1). Arteries, the pulsating vessels, originate from the left ventricle of heart and follow it during contraction and expansion. Their role is to spread the brutal spirit to the whole body. Arteries are composed of two layers: the inner layer is dense as it is the true receptacle of the spirit. Its bers are circumferential. Hence, the [function of] contraction, which expels the exhaled residue, is taken over by this layer. The outer layer is composed of longitudinal and oblique bers. So that, the [function of] expansion, which absorbs the air, takes place by this layer. However, the venous artery is a single layer and goes to the lung. For the lung is continuously moving and for it not being heavy, the venous artery was created in one layer (pp. 143144). Know that two pulsating vessels originate from the left cardiac ventricle: one is small and composed of a single layer, which is called the venous artery. The venous artery goes to the lung and branches there to take part in respiration with the heart supplying nutrients to the lung. The other vessel, which also originates from this side, is large and is called the aorta. Originating from the heart, this vessel divides

into two branches: the small one goes to the right-sided ventricle and is dispersed there. Another branch encircles the heart and supplies its parts. The remaining segment of this vessel divides into two branches: one branch goes upward and another downward. The descending artery is larger because the organs located below the heart are numerous and also larger than those located above the heart. The ascending artery divides into two branches, much of which goes to the liver toward the right until it enters the soft esh in the upper portions of the chest (pp. 144145). Some believe that there is another layer inside the arteries, which is like a spider-web (cobweb) and is seen in most arteries; this remark is not valid. The arteries branch from the left ventricle of the heart as the right side is closer to the liver so as to absorb nutrients (p. 146). The conclusion: On the complex organs. The heart, the noblest organ, and absolute master is the location of a brutal spirit and is composed of multi-positioned bers, hard esh and a thick membrane encircling it. As the palm surrounds an object laid within it, lung surrounds the heart in the same way. The heart looks like a pine with its base facing upward and it is located in the thoracic cavity where its conoid tip is inclined toward the left side. The bottom of the heart contains a cartilaginous bone, which is called the base of the heart. The heart has two cavities: one on the right side and the other on the left side, both moving continuously. The left-sided cavity has greater movement because it places the brutal spirit and contains much blood. The origin of arteries is from the left side. And the right cavity has two membranous passages: from one the blood comes to the heart from the liver and from the next, blood goes from the heart to the lung. The left ventricle also has two passages: one is for the entry of air from the lung to the heart and the other is for the commencement of pulsating vessels or arteries. The hole between the right and left cavities is wider on the right side and gradually becomes narrower as it goes to the left side. Through this hole, pure

Fig. 1. Illustration of the arteries from the Tashrihi Mansuri, from a manuscript dated 1261 Hijri, ascribed by Mirza Esfahani (reproduced with kind permission of Tabriz National Library).

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blood ows from the right to the left side. Each of these two cavities has two prominences on the outside that look like auricles and are called the cardiac auricles. Others say that the heart contains three cavities; the rst and last ventricles are large and the middle one is small. Surrounding the heart is a membrane for its protection and is called the cardiac sheath (pericardium). This sheath is separate from the heart, so that when the sheath is damaged, the heart remains intact. Moreover, it hinders decomposition [of the heart] during its expansion (pp. 153155). 4. Discussion Mansur's anatomical discourses obviously had many errors. Mansur was a cardiocentrist believing that the heart was the noblest of all organs and was the rst to be formed in the body. He made a brief note on the Aristotelian theory of the three-chambered heart while basing the bulk of his hypotheses on a biventricular heart. Although he was reluctant to reject or accept either theory, it appears that he favored the latter. Not surprising, the pulmonary circulation was omitted, and instead the presence of an open interventricular foramen for transmitting the blood between the ventricles was wrongfully assumed, an assumption that was also made by Galen and Avicenna several centuries before. The rst passages of the introduction in Mansur's Anatomy deal with one of the more controversial topics of his time: what organ develops rst in the fetus. Different ideas were confronted by giving references to Aristotle's beliefs on the heart, Hippocrates's beliefs on the brain, Rhazes' beliefs on the liver and Avicenna's belief that the umbilicus is the rst organ to form. Trying to resolve this controversy, Mansur quoted Imam Fakhr al-Din Razi, a prominent Persian theologian, who stated there is no inconsistency between the remarks of Hippocrates, Rhazes and Avicenna. This is because, although the heart precedes other organs in development, it is not apparent and discernible in the early stage of development. Mansur himself agreed that the heart was the rst organ to develop by relying upon a famous prophetic tradition (Hadeeth): Beware! There is a piece of esh in the body. If it is healthy, the whole body is healthy. If it becomes unhealthy, the whole body becomes unhealthy. Verily, this esh is the heart (translation from [17], page 80). Such strong reliance on the prophetic tradition for understanding the human body is a unique feature of Mansur's Anatomy. In fact, this introduction of prophetic medicine might have been an effort to demonstrate the strengths of Islam, and thereby inuence the Timurids to religious tolerance (p. 266) [14]. The importance of Mansur's Anatomy does not lie in its writing but rather in its originality of illustrations, which were publicized in Persia after several centuries of ambiguity and obscurity. Older manuscripts of Mansur's Anatomy have contained 5 color illustrations of the skeleton, peripheral nerves, arteries, veins (Fig. 2) and muscles [7]. In all of the illustrations, the entire body was shown. Additional illustrations have included that of a pregnant woman (Fig. 3) and one of surface anatomy indicating skin areas for cupping [7]. Although similarities have been observed between some of the anatomical plates and earlier Latin drawings, the color plate of a pregnant woman is thought to be the original work of Mansur and to be a superimposition of a gravid uterus onto the arterial plate [6,15]. The fact that Mansur selected drawing of arteries to demonstrate a gravid uterus may indirectly indicate that he regarded the fetoplacental unit as a part of the circulation. Notably, later copies of Mansur's Anatomy from the 19th century were supplemented with newer images showing a more complex and sophisticated anatomy and depicting the relationships between nerves, arteries and organs [18]. 5. Conclusions Throughout history, illustrations had played a key role in the promotion and evolution of medicine by providing a medium for
Fig. 3. Illustration of a pregnant woman from the Tashrihi Mansuri, from a manuscript dated 1261 Hijri, ascribed by Mirza Esfahani (reproduced with kind permission of Tabriz National Library).

Fig. 2. Illustration of the veins from the Tashrihi Mansuri, from a manuscript dated 1261 Hijri, ascribed by Mirza Esfahani (reproduced with kind permission of Tabriz National Library).

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transmission of scientic observations. Due to religious prohibitions [7,14], color drawings of the human body did not appear in medieval Persia and during the Islamic Golden Age. This tradition, however, has been overlooked with the publication of the rst color atlas and text of human anatomy, Mansur's Anatomy. This book was so inuential that the history of anatomy in Persia is divided into two partsbefore and after the appearance of Mansur's Anatomy [14]. Acknowledgments

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The authors are grateful to the Tabriz Central Library for its permission to include images from the manuscript of the Tashrihi Mansuri in this paper. The authors are also thankful to Dr. Kazem Khodadoost for his kind assistance in preparation of this paper. The authors of this manuscript have certied that they comply with the Principles of Ethical Publications in the International Journal of Cardiology [19]. References

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Please cite this article as: Khalili M, et al, Illustration of the heart and blood vessels in medieval times, Int J Cardiol (2010), doi:10.1016/j. ijcard.2009.11.061