November 2014 - Newsletter
“Vivitur ingenio, caetera mortis erunt” (“Genius lives on, all else is mortal”)
Figure 1. Andreas Vesalius
Crucial to the specialty of Regional Anesthesia and Pain Medicine (RAPM), is human anatomy. In fact, it is often said that RAPM is the “practice of applied anatomy”. Therefore, it is fitting that on the occasion of his 500th birthday, we celebrate the life and work of the brilliant anatomist, Andreas Vesalius, (1514-1564) the founder of modern anatomy. Some historians argue that he influenced the thinking of his contemporaries to such an extent that our understanding of anatomy can be divided into pre and post-Vesalius eras.
From left to right: Klaas Buyse MD, Ilvana Vukovic MD, Admir Hadzic MD, Xavier Sala-Blanch MD, Emily Lynn MD, Jeff Gadsden MD and Catherine Vandeptte MD in Leuven, January 2012.
NYSORA's international team has collaborated with the Catholic University at Leuven (KUL) and the Andreas Vesalius Institute of Anatomy in Leuven to research Vesalius. Consequently, our team was privileged to gain access to some of the well-known historians of Vesalius in his home country Brabant, now Belgium. By all counts, Vesalius was an extraordinary man whose revolutionary contributions to medicine were so ahead of their time that they often involved close brushes with the law, which only served to further fuel the mystique around the man. We highlighted the lifeWe highlighted the life and work of Andreas Vesalius in November/December 2014 issue of Regional Anesthesia and Pain Medicine (Reg Anesth Pain Med. 2014 Nov-Dec;39(6):450-5. ; http://www.ncbi.nlm.nih.gov/pubmed/25340483). After a visit to one of several museum exhibits in Vesalius “home town”, Leuven Belgium, we felt compelled to share more information and the festive atmosphere in honor of one of the greatest sons of Flanders.
Mural on Vesalius Institute in Leuven, Belgium
Vesalius posters throughout Leuven, Belgium
Who was Andreas Vesalius?
The Early Life of Andreas Vesalius
Anatomy before Vesalius
"Claude Galien". Lithograph by Pierre Roche Vigneron. (Paris: Lith de Gregoire et Deneux, ca. 1865)
His anatomical theories were standard text for medical students for over 1300 years. Like Vesalius, Galenus aspired to break the bygone boundaries of the science of the era, while his contemporaries clutched on and taught scientific principles that were already accepted.iii Unfortunately, Galen wrote about anatomy during a time when a system of anatomical nomenclature did not exist, so it was difficult to translate and understand all of his texts. Moreover, Galen did not have a way of effectively spreading his knowledge, particularly since he wrote in Greek and everything needed to be translated, resulting in poor translations in the circulation (as opposed to Vesalius who knew his classics!). The printing press had not yet been invented, so his manuscripts had to be copied by hand, creating another obstacle and errors in reproduction.6 Importantly however, his work was subject to practical limitations as the dissection of human bodies was considered blasphemy and thus forbidden by the Roman Empire. Consequently, Galen was limited to work on animal dissections, usually on the Barbary monkey.
In an apparently mind-shifting experiment in 1541, Vesalius put the skeleton of a monkey and the skeleton of a human, side by side. During his examination, he found a process of the lumbar vertebrae in the monkey that was not present in the human. Galen's teachings, however, had described the human vertebrae as having that process, and Vesalius was suddenly struck with the realization that Galen had never dissected a man! He decried “I cannot wonder enough at my stupidity and trust in Galen which prevented me from seeing this before.”7
Anatomy during the Renaissance
An illustration of a corpse hanging off gallows poll
Vesalius readily voiced his disdain for such inconsistencies in learning. He wrote in his book, Fabrica, “For, except for eight abdominal muscles shamefully mangled and in the wrong order, no other muscle or any bone, and much less an accurate series of the nerves, veins or arteries was ever demonstrated to me by anyone.” His radical views about hands-on learning not only changed the study of anatomy, but also stirred a widespread revolution. However, being labeled a “radical,” Vesalius encountered considerable resistance by the followers of Galen and by older professors who also preached that students should not study or learn from pictures of the anatomy.
Undaunted, Vesalius proceeded to perform the dissections of the human body himself and depicted his findings in pictures. He wrote, “My study of anatomy would never have succeeded had I, when working at medicine in Paris, been willing that the viscera should be merely shown to me and my fellow students ... I had to put my own hand to the business.” With this mindset, Vesalius did put his hands down to the business and began studying the anatomy, initially on the only part of the body that was freely accessible for study: the skeleton. In the 1500s, burials were often botched and incomplete, leaving bones scattered about cemeteries. Vesalius spent many hours studying these bones on the burial grounds of the Church of Innocents in Paris (now Les Buttes Chaumont). By moonlight, Vesalius and fellow students snuck onto the grounds to collect and study any scattered bones, risking being caught by the Church, or attacked by hungry dogs, who themselves had come to the cemetery in search on human remains. 4
During a walk outside the city walls of Louvain, Vesalius came across a skeleton chained to a wooden stake. Guessing that the skeleton was that of a criminal who had been burned at the stake, and noting that it was dried and mostly intact, Vesalius decided to steal it. He smuggled the skeleton, piece by piece over the next few days, and then reassembled it at home. 4 During his time in medical school, Vesalius became so adept at the study of anatomy that his fellow students and his teachers soon asked him to conduct the dissections instead of the barbers. iii
Figure 2. From the Vesalius Exhibition, Leuven, Belgium
The Fabrica had more influence on the evolution of anatomy and surgery than any previously published medical book.6 The Fabrica, thanks to the printing press, was replicated both quickly and accurately. It was distributed throughout Europe, and was quickly adopted as the standard reference text for anatomy. The Fabrica was also cleverly dedicated to the Holy Roman Emperor, Charles V, in the hopes of garnering favor and protection from the Emperor to dodge suspicions of heresy. The publication of Fabrica also helped Vesalius to secure the position of imperial physician, in which he served until Charles V abdicated in 1556.
The Fabrica is widely held as the first great work of modern science.7 In the Middle Ages, physicians had difficulties performing autopsies to find causes of death as they did not know the structure of the body and could not recognize a pathology if they came across one. Consequently, the Fabrica had a vast amount of illustrations with clear anatomical detail. Vesalius combined drawings with words and labeled bones and organs, which had not been done before, FIGURE 2. He was also the first to describe the fine structure of nerves, veins, muscles, arteries and the skeleton. Despite the prevailing Galenist attitude that anatomical illustrations hindered the study of anatomy, Vesalius understood the importance of illustrations, and had Stephen van Calcar, a German-born Italian painter, one of Titian's apprentices, completed the images for the Fabrica rather then attempting to do the drawings himself.
Figure 3. The Fabrica
The drawing on the title page of the Fabrica shows Vesalius conducting a dissection on a woman, FIGURE below. Within arm's reach, there is a scalpel, a razor, a pen, an inkwell, a lighted candle and a piece of paper. The barbers, who would have been performing the dissection, are practically under the table, which suggests Vesalius' new way of teaching that preferred professors dissecting with their own hands. The Fabrica is composed of seven books: Book I describes the bones, Book II the muscles, Book III the blood vessels, Book IV the nervous system, Book V the internal organs of the abdomen, Book VI the heart and lungs, and Book VII the brain.
Andreas Vesalius and the Nervous System
Figure 4. Illustration of the nervous system as published in Fabrica
The perils of thinking different in 1500's
Eventually Vesalius managed to distance himself from his critics and saw the greater picture. His life experiences presented him with opportunities that many others did not have and those opportunities fueled his thirst for knowledge. For example, during his time as a court physician, he was often sent with the army to treat the wounded and to perform autopsies on the dead. He was also offered a temporary position as a lecturer in Italy, and for a few months, he left the imperial court to return to Italy. Over the years, Vesalius was able to perform more dissections and continued to learn through his observations of the human body. In 1555, he decided that he had to publish an updated version of the Fabrica in which the mistakes were corrected and new observations he had made were presented. In the 1555 publication, the world was introduced to valves in the veins and a much more detailed and accurate description of the human fetus. Much of Vesalius' later life however, is obscured. What is known is that upon returning from a convoluted trip to the Holy Land in 1564, the ship he was on was hit by a storm and driven ashore on the Greek island of Zakynthos, where he later died.
Piecing it all together
Sir Isaac Newton wrote, “If I have seen further, it is by standing upon the shoulders of giants.” Indeed, as anesthesiologists, we also stand on the shoulders of many great physician scientists like Vesalius as we continue to explore human anatomy with ultrasound and other innovative and high-resolution imaging. His relentless quest for truth and efforts to teach others helped to pioneer future breakthroughs in medicine. In this 500th anniversary celebration, we pay tribute to Andreas Vesalius for his courage to question the dogma and to push the boundaries of the law leaving us with his great discoveries in science and anatomy.
Adriaen Backer: The anatomy Lesson of dr. Frederick Ruysch, 1670, Amsterdam Museum.
Functional Anatomy of Axillary Brachial Plexus. Artist, Vali Lancea.
Even as modern medicine relies increasingly more on sophisticated imaging technologies, multi-dimensional modeling, and simulation for acquisition of skills necessary to practice medicine, anatomy and physiology to this day remain the pillars of medicine. In keeping with advances in medicine, the modern-day Vesalius institute has implemented a number of training programs for physicians in a need of acquiring highly technical operative skills required to perform complicated surgical procedures, such as joint replacement, various laparoscopic surgeries, as well as modern methods of ultrasound-guided regional anesthesia and pain medicine procedures. Therefore, even 500 years after work of Andreas Vesalius, anatomy remains an essential knowledge skill and basis for practice of medicine and surgery.
Upcoming 2nd Edition of NYSORA's Educational Posters.
Despite the widespread availability of multiple anatomical atlases, computer programs and applications, there is still not replacement for dissection and training in cadavers.
i Famous Biologists. Andreas Vesalius. Available at: http://famousbiologists.org/andreas-vesalius/ Accessed May 13, 2014.
ii 500 Years Vesalius. Basel, Switzerland. Karger Publishers. (Karger Publishers) Accessed May 13, 2014.
iii Toledo-Pereyra L. De Humani Corporis Fabrica Surgical Revolution. J Invest Surg 2008; 21(5): 232-6.
iv Tarshis J. The Father of Modern Anatomy Andreas Vesalius. New York: Dial Press, 1969.
v Sir Foster M. Lectures on the History of Physiology during the 16, 17 and 18 Centuries. Cambridge: At the University Press, 1901.
vi Moes R. Andreas Vesalius and the anatomy of the upper extremity. J Hand Surg 1976: 1; 23-28.
vii Hunt D. Talks on the History of Medicine. Boston Med Surg J 1898; 139:229-234. (Hunt, 1898)
viii Sir Cope Z. How medicine became a science. J Frank Inst 1956; 261:81-91.
ix Nutton V. The Man. http://vesalius.northwestern.edu/chapters/FA.aa.02.html Accessed May 13, 2014.
x Malomo AO, Idowu OE, Osuagwu FC. Lessons from History: Human Anatomy, from the Origin to the Renaissance. Int J Morphol 2006; 24:99-104.
xi Vesalius. De humani corporis fabrica libri septem. Fol*3r. Basel: Ex officina Joannis Oporini, 1543.
xii Vallejo-Manzur F, Perkins Y, Varon J, Baskett P. Andreas Vesalius, the concept of an artificial airway. Resuscitation 2003; 56:3-7.
xiii Copernicus N. De Revolutionibus Orbium Coelestium. Norimbergae: apud Ioh. Petreium, 1543
xiv Fara P. Versions of Vesalius. Endeavour 2011; 35:5-6.
xv Vesalius. De humani corporis fabrica libri septem. p315. Basel: Ex officina Joannis Oporini, 1543.
xvi Vesalius. De humani corporis fabrica libri septem. p324. Basel: Ex officina Joannis Oporini, 1543.
xvii O'Malley CD. Andreas Vesalius of Brussels 1514–1564. Berkeley, CA: University of California Press, 1964.
xviii Biesbrouck M, Vesaliana: an updated bibliography of Andreas Vesalius. http://www.andreasvesalius.be/ Accessed May 13, 2014.
Kamen Vlassakov, MD,
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