The Evolution of Modern Medicine: Chapter IV - VESALIUS

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VESALIUS

THE same year, 1542, saw a very different picture in the far-famed city of Padua, "nursery of the arts." The central figure was a man not yet in the prime of life, and justly full of its pride, as you may see from his portrait. Like Aristotle and Hippocrates cradled and nurtured in an AEsculapian family, Vesalius was from his childhood a student of nature, and was now a wandering scholar, far from his Belgian home. But in Italy he had found what neither Louvain nor Paris could give, freedom in his studies and golden opportunities for research in anatomy. What an impression he must have made on the student body at Padua may be judged from the fact that shortly after his graduation in December, 1537, at the age of twenty-four, he was elected to the chair of anatomy and surgery. Two things favored him—an insatiate desire to see and handle for himself the parts of the human frame, and an opportunity, such as had never before been offered to the teacher, to obtain material for the study of human anatomy. Learned with all the learning of the Grecians and of the Arabians, Vesalius grasped, as no modern before him had done, the cardinal fact that to know the human machine and its working, it is necessary first to know its parts—its fabric.

To appreciate the work of this great man we must go back in a brief review of the growth of the study of anatomy.

Among the Greeks only the Alexandrians knew human anatomy. What their knowledge was we know at second hand, but the evidence is plain that they knew a great deal. Galen's anatomy was first-class and was based on the Alexandrians and on his studies of the ape and the pig. We have already noted how much superior was his osteology to that of Mundinus. Between the Alexandrians and the early days of the School of Salernum we have no record of systematic dissections of the human body. It is even doubtful if these were permitted at Salernum. Neuburger states that the instructions of Frederick II as to dissections were merely nominal.

How atrocious was the anatomy of the early Middle Ages may be gathered from the cuts in the works of Henri de Mondeville. In the Bodleian Library is a remarkable Latin anatomical treatise of the late thirteenth century, of English provenance, one illustration from which will suffice to show the ignorance of the author. Mundinus of Bologna, one of the first men in the Middle Ages to study anatomy from the subject, was under the strong domination of the Arabians, from whom he appears to have received a very imperfect Galenic anatomy. From this date we meet with occasional dissections at various schools, but we have seen that in the elaborate curriculum of the University of Padua in the middle of the fifteenth century there was no provision for the study of the subject. Even well into the sixteenth century dissections were not common, and the old practice was followed of holding a professorial discourse, while the butcher, or barber surgeon, opened the cavities of the body. A member of a famous Basel family of physicians, Felix Plater, has left us in his autobiography(19) details of the dissections he witnessed at Montpellier between November 14, 1552, and January 10, 1557, only eleven in number. How difficult it was at that time to get subjects is shown by the risks they ran in "body-snatching" expeditions, of which he records three.

And now came the real maker of modern anatomy. Andreas Vesalius had a good start in life. Of a family long associated with the profession, his father occupied the position of apothecary to Charles V, whom he accompanied on his journeys and campaigns. Trained at Louvain, he had, from his earliest youth, an ardent desire to dissect, and cut up mice and rats, and even cats and dogs. To Paris, the strong school of the period, he went in 1533, and studied under two men of great renown, Jacob Sylvius and Guinterius. Both were strong Galenists and regarded the Master as an infallible authority. He had as a fellow prosector, under the latter, the unfortunate Servetus. The story of his troubles and trials in getting bones and subjects you may read in Roth's "Life."(20) Many interesting biographical details are also to be found in his own writings. He returned for a time to Louvain, and here he published his first book, a commentary on the "Almansor" of Rhazes, in 1537.

Finding it difficult, either in Paris or Louvain, to pursue his anatomical studies, he decided to go to Italy where, at Venice and Padua, the opportunities were greater. At Venice, he attended the practice of a hospital (now a barracks) which was in charge of the Theatiner Order. I show you a photograph of the building taken last year. And here a strange destiny brought two men together. In 1537, another pilgrim was working in Venice waiting to be joined by his six disciples. After long years of probation, Ignatius Loyola was ready to start on the conquest of a very different world. Devoted to the sick and to the poor, he attached himself to the Theatiner Order, and in the wards of the hospital and the quadrangle, the fiery, dark-eyed, little Basque must frequently have come into contact with the sturdy young Belgian, busy with his clinical studies and his anatomy. Both were to achieve phenomenal success—the one in a few years to revolutionize anatomy, the other within twenty years to be the controller of universities, the counsellor of kings, and the founder of the most famous order in the Roman Catholic Church. It was in this hospital that Vesalius made observations on the China-root, on which he published a monograph in 1546. The Paduan School was close to Venice and associated with it, so that the young student had probably many opportunities of going to and fro. On the sixth of December, 1537, before he had reached his twenty-fourth year and shortly after taking his degree, he was elected to the chair of surgery and anatomy at Padua.

The task Vesalius set himself to accomplish was to give an accurate description of all the parts of the human body, with proper illustrations. He must have had abundant material, more, probably, than any teacher before him had ever had at his disposal. We do not know where he conducted his dissections, as the old amphitheatre has disappeared, but it must have been very different from the tiny one put up by his successor, Fabricius, in 1594. Possibly it was only a temporary building, for he says in the second edition of the "Fabrica" that he had a splendid lecture theatre which accommodated more than five hundred spectators (p. 681).

With Vesalius disappeared the old didactic method of teaching anatomy. He did his own dissections, made his own preparations, and, when human subjects were scarce, employed dogs, pigs or cats, and occasionally a monkey. For five years he taught and worked at Padua. He is known to have given public demonstrations in Bologna and elsewhere. In the "China-root" he remarks that he once taught in three universities in one year. The first fruit of his work is of great importance in connection with the evolution of his knowledge. In 1538, he published six anatomical tables issued apparently in single leaves. Of the famous "Tabulae Anatomicae" only two copies are known, one in the San Marco Library, Venice, and the other in the possession of Sir John Stirling-Maxwell, whose father had it reproduced in facsimile (thirty copies only) in 1874. Some of the figures were drawn by Vesalius himself, and some are from the pencil of his friend and countryman, Stephan van Calcar. Those plates were extensively pirated. About this time he also edited for the Giunti some of the anatomical works of Galen.(21)

We know very little of his private life at Padua. His most important colleague in the faculty was the famous Montanus, professor of medicine. Among his students and associates was the Englishman Caius, who lived in the same house with him. When the output is considered, he cannot have had much spare time at Padua.

He did not create human anatomy—that had been done by the Alexandrians—but he studied it in so orderly and thorough a manner that for the first time in history it could be presented in a way that explained the entire structure of the human body. Early in 1542 the MS. was ready; the drawings had been made with infinite care, the blocks for the figures had been cut, and in September, he wrote to Oporinus urging that the greatest pains should be taken with the book, that the paper should be strong and of equal thickness, the workmen chosen for their skill, and that every detail of the pictures must be distinctly visible. He writes with the confidence of a man who realized the significance of the work he had done. It is difficult to speak in terms of moderation of the "Fabrica." To appreciate its relative value one must compare it with the other anatomical works of the period, and for this purpose I put before you two figures from a text-book on the subject that was available for students during the first half of the sixteenth century. In the figures and text of the "Fabrica" we have anatomy as we know it; and let us be honest and say, too, largely as Galen knew it. Time will not allow me to go into the question of the relations of these two great anatomists, but we must remember that at this period Galen ruled supreme, and was regarded in the schools as infallible. And now, after five years of incessant labor, Vesalius was prepared to leave his much loved Padua and his devoted students. He had accomplished an extraordinary work. He knew, I feel sure, what he had done. He knew that the MSS. contained something that the world had not seen since the great Pergamenian sent the rolls of his "Manual of Anatomy" among his friends. Too precious to entrust to any printer but the best—and the best in the middle of the sixteenth century was Transalpine—he was preparing to go north with the precious burden. We can picture the youthful teacher—he was but twenty-eight—among students in a university which they themselves controlled—some of them perhaps the very men who five years before had elected him—at the last meeting with his class, perhaps giving a final demonstration of the woodcuts, which were of an accuracy and beauty never seen before by students' eyes, and reading his introduction. There would be sad hearts at the parting, for never had anyone taught anatomy as he had taught it—no one had ever known anatomy as he knew it. But the strong, confident look was on his face and with the courage of youth and sure of the future, he would picture a happy return to attack new and untried problems. Little did he dream that his happy days as student and teacher were finished, that his work as an anatomist was over, that the most brilliant and epoch-making part of his career as a professor was a thing of the past. A year or more was spent at Basel with his friend Oporinus supervising the printing of the great work, which appeared in 1543 with the title "De Humani Corporis Fabrica." The worth of a book, as of a man, must be judged by results, and, so judged, the "Fabrica" is one of the great books of the world, and would come in any century of volumes which embraced the richest harvest of the human mind. In medicine, it represents the full flower of the Renaissance. As a book it is a sumptuous tome a worthy setting of his jewel—paper, type and illustration to match, as you may see for yourselves in this folio—the chef d'oeuvre of any medical library.

In every section, Vesalius enlarged and corrected the work of Galen. Into the details we need not enter: they are all given in Roth's monograph, and it is a chapter of ancient history not specially illuminating.

Never did a great piece of literary work have a better setting. Vesalius must have had a keen appreciation of the artistic side of the art of printing, and he must also have realized the fact that the masters of the art had by this time moved north of the Alps.

While superintending the printing of the precious work in the winter of 1542-1543 in Basel, Vesalius prepared for the medical school a skeleton from the body of an executed man, which is probably the earliest preparation of the kind in Europe. How little anatomy had been studied at the period may be judged from that fact that there had been no dissection at Basel since 1531.(22) The specimen is now in the Vesalianum, Basel, of which I show you a picture taken by Dr. Harvey Cushing. From the typographical standpoint no more superb volume on anatomy has been issued from any press, except indeed the second edition, issued in 1555. The paper is, as Vesalius directed, strong and good, but it is not, as he asked, always of equal thickness; as a rule it is thick and heavy, but there are copies on a good paper of a much lighter quality. The illustrations drawn by his friend and fellow countryman, van Calcar, are very much in advance of anything previously seen, except those of Leonardo. The title-page, one of the most celebrated pictures in the history of medicine, shows Vesalius in a large amphitheatre (an imaginary one of the artist, I am afraid) dissecting a female subject. He is demonstrating the abdomen to a group of students about the table, but standing in the auditorium are elderly citizens and even women. One student is reading from an open book. There is a monkey on one side of the picture and a dog on the other. Above the picture on a shield are the three weasels, the arms of Vesal. The reproduction which I show you here is from the "Epitome"—a smaller work issued before (?) the "Fabrica," with rather larger plates, two of which represent nude human bodies and are not reproduced in the great work. The freshest and most beautiful copy is the one on vellum which formerly belonged to Dr. Mead, now in the British Museum, and from it this picture was taken. One of the most interesting features of the book are the full-page illustrations of the anatomy of the arteries, veins and nerves. They had not in those days the art of making corrosion preparations, but they could in some way dissect to their finest ramifications the arteries, veins and nerves, which were then spread on boards and dried. Several such preparations are now at the College of Physicians in London, brought from Padua by Harvey. The plates of the muscles are remarkably good, more correct, though not better perhaps, on the whole, than some of Leonardo's.

Vesalius had no idea of a general circulation. Though he had escaped from the domination of the great Pergamenian in anatomy, he was still his follower in physiology. The two figures annexed, taken from one of the two existing copies of the "Tabulae Anatomica," are unique in anatomical illustration, and are of special value as illustrating the notion of the vascular system that prevailed until Harvey's day. I have already called your attention to Galen's view of the two separate systems, one containing the coarse, venous blood for the general nutrition of the body, the other the arterial, full of a thinner, warmer blood with which were distributed the vital spirits and the vital heat. The veins had their origin in the liver; the superior vena cava communicated with the right heart, and, as Galen taught, some blood was distributed to the lungs; but the two systems were closed, though Galen believed there was a communication at the periphery between the arteries and veins. Vesalius accepted Galen's view that there is some communication between the venous and arterial systems through pores in the septum of the ventricles, though he had his doubts, and in the second edition of his book (1555) says that inspite of the authority of the Prince of Physicians he cannot see how the smallest quantity of blood could be transmitted through so dense a muscular septum. Two years before this (1553),(*) his old fellow student, Michael Servetus, had in his "Christianismi Restitutio" annatomical touch with one another!

The publication of the "Fabrica" shook the medical world to its foundations. Galen ruled supreme in the schools: to doubt him in the least particular roused the same kind of feeling as did doubts on the verbal inspiration of the Scriptures fifty years ago! His old teachers in Paris were up in arms: Sylvius, nostrae aetatis medicorum decus, as Vesalius calls him, wrote furious letters, and later spoke of him as a madman (vaesanus). The younger men were with him and he had many friends, but he had aroused a roaring tide of detraction against which he protested a few years later in his work on the "China-root," which is full of details about the "Fabrica." In a fit of temper he threw his notes on Galen and other MSS. in the fire. No sadder page exists in medical writings than the one in which Vesalius tells of the burning of his books and MSS. It is here reproduced and translated.(23) His life for a couple of years is not easy to follow, but we know that in 1546 he took service with Charles V as his body physician, and the greatest anatomist of his age was lost in the wanderings of court and campaigns. He became an active practitioner, a distinguished surgeon, much consulted by his colleagues, and there are references to many of his cases, the most important of which are to internal aneurysms, which he was one of the first to recognize. In 1555 he brought out the second edition of the "Fabrica," an even more sumptuous volume than the first.

"All these impediments I made light of; for I was too young to seek gain by my art, and I was sustained by my eager desire to learn and to promote the studies in which I shared. I say nothing of my diligence in anatomizing—those who attended my lectures in Italy know how I spent three whole weeks over a single public dissection. But consider that in one year I once taught in three different universities. If I had put off the task of writing till this time; if I were now just beginning to digest my materials; students would not have had the use of my anatomical labours, which posterity may or may not judge superior to the rechauffes formerly in use, whether of Mesua, of Gatinaria, of some Stephanus or other on the differences, causes and symptoms of diseases, or, lastly, of a part of Servitor's pharmacopoeia. As to my notes, which had grown into a huge volume, they were all destroyed by me; and on the same day there similarly perished the whole of my paraphrase on the ten books of Rhazes to King Almansor, which had been composed by me with far more care than the one which is prefaced to the ninth book. With these also went the books of some author or other on the formulae and preparation of medicines, to which I had added much matter of my own which I judged to be not without utility; and the same fate overtook all the books of Galen which I had used in learning anatomy, and which I had liberally disfigured in the usual fashion. I was on the point of leaving Italy and going to Court; those physicians you know of had made to the Emperor and to the nobles a most unfavourable report of my books and of all that is published nowadays for the promotion of study; I therefore burnt all these works that I have mentioned, thinking at the same time that it would be an easy matter to abstain from writing for the future. I must show that I have since repented more than once of my impatience, and regretted that I did not take the advice of the friends who were then with me."

There is no such pathetic tragedy in the history of our profession. Before the age of thirty Vesalius had effected a revolution in anatomy; he became the valued physician of the greatest court of Europe; but call no man happy till he is dead! A mystery surrounds his last days. The story is that he had obtained permission to perform a post-mortem examination on the body of a young Spanish nobleman, whom he had attended. When the body was opened, the spectators to their horror saw the heart beating, and there were signs of life! Accused, so it is said, by the Inquisition of murder and also of general impiety he only escaped through the intervention of the King, with the condition that he make a pilgrimage to the Holy Land. In carrying this out in 1564 he was wrecked on the island of Zante, where he died of a fever or of exhaustion, in the fiftieth year of his age.

To the North American Review, November, 1902, Edith Wharton contributed a poem on "Vesalius in Zante," in which she pictures his life, so full of accomplishment, so full of regrets—regrets accentuated by the receipt of an anatomical treatise by Fallopius, the successor to the chair in Padua! She makes him say:

But between Mundinus and Vesalius, anatomy had been studied by a group of men to whom I must, in passing, pay a tribute. The great artists Raphael, Michael Angelo and Albrecht Durer were keen students of the human form. There is an anatomical sketch by Michael Angelo in the Ashmolean Museum, Oxford, which I here reproduce.(*) Durer's famous work on "Human Proportion," published in 1528, contains excellent figures, but no sketches of dissections. But greater than any of these, and antedating them, is Leonardo da Vinci, the one universal genius in whom the new spirit was incarnate—the Moses who alone among his contemporaries saw the promised land. How far Leonardo was indebted to his friend and fellow student, della Torre, at Pavia we do not know, nor does it matter in face of the indubitable fact that in the many anatomical sketches from his hand we have the first accurate representation of the structure of the body. Glance at the three figures of the spine which I have had photographed side by side, one from Leonardo, one from Vesalius and the other from Vandyke Carter, who did the drawings in Gray's "Anatomy" (1st ed., 1856). They are all of the same type, scientific, anatomical drawings, and that of Leonardo was done fifty years before Vesalius! Compare, too, this figure of the bones of the foot with a similar one from Vesalius.(24) Insatiate in experiment, intellectually as greedy as Aristotle, painter, poet, sculptor, engineer, architect, mathematician, chemist, botanist, aeronaut, musician and withal a dreamer and mystic, full accomplishment in any one department was not for him! A passionate desire for a mastery of nature's secrets made him a fierce thing, replete with too much rage! But for us a record remains—Leonardo was the first of modern anatomists, and fifty years later, into the breach he made, Vesalius entered.(25)

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Osler, William. 2006. The Evolution of Modern Medicine. Urbana, Illinois: Project Gutenberg. Retrieved April 2022 from https://www.gutenberg.org/files/1566/1566-h/1566-h.htm#link2H_4_0026

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