Andreas Vesalius, the Reformer of Anatomy

by James Moores Ball

The Anatomical Renaissance

Italy in the sixteenth century was the fount from which issued a ceaseless stream of anatomical discoveries. The ancient and illustrious Universities of Bologna, Pavia, Padua, Pisa and Rome, eclipsed the schools of Paris and Montpellier, of Toulouse and Salamanca; and the Italian peninsula, which, in early mediaeval times, had gloried in the skill of the physicians of Salernum, a second time became the medical centre of Europe. Vesalius and his pupil, Fallopius, taught at Padua; the ancient fame of Bologna was supported by Arantius and Varolius; Vidius, returned from establishing the anatomical school at Paris, taught at Pisa; Eustachius was at Rome, Ingrassias lectured at Naples, and the fame of the New Anatomy spread throughout the world. The Italian cities were filled with students from foreign lands. Padua had more than one thousand new students every year, salaries were paid to her one hundred professors, and medicine was looked upon as a noble profession.

While the Italians were the leaders in progress, the Germans were still lecturing on Galen and Avicenna, the English had done almost nothing, and the Collége de France was not established until 1530.

Legalized by imperial authority and sanctioned by the Church, dissection was no longer regarded as a crime. A bull by Pope Boniface VIII., issued in the year 1300, forbidding the evisceration of the dead and the boiling of their bodies to secure the bones for consecrated ground, as was done by the Crusaders, was wrongly interpreted as forbidding anatomical dissection. Two centuries later the Popes, standing in the vanguard of science, permitted dissections to be made in all the Italian medical schools, and paved the way for the Anatomical Renaissance.

Great things were done in the sixteenth century. Under the scalpel and pen of Vesalius, anatomy was revolutionized. Surgery was guided into new paths by Ambroise Paré; and obstetrics, thanks to the labors of Eucharius Rhodion and Jacques Guillemeau, began to assume its legitimate place among the medical sciences. Servetus, visionary and argumentative, correctly described the pulmonary circulation in a theological work which was burned with its author. Eustachius, Columbus and Fallopius widened the path which had been blazed by Vesalius. Arantius, Caesalpinus and Fabricius added materially to anatomical science. The labors of all these great masters prepared the way for the greatest event occurring in the seventeenth century, namely, William Harvey’s discovery of the circulatory movement of the blood.

INITIAL LETTER BY VESALIUS
(From the “Fabrica”, 1543)

CHAPTER FIRST
Anatomy in Ancient Times

Egypt and Greece were the sources of the medical learning of the ancient world. Although the Egyptians and early Greeks possessed a certain amount of anatomical knowledge, which was gained in the one instance by the practice of embalming and in the other by an examination of the bones, no real progress could be made because of the laws, customs and prejudices of those ancient peoples. Thus we find the Egyptians stoning the operator who opened the abdomen in order that the body might be embalmed; and the Greeks inflicted the death penalty on those of their generals who, after a battle, neglected to bury or burn the remains of the slain.

HIPPOCRATES

In the time of Hippocrates, whose life extended approximately over the period between 460-377 B.C., Greek medicine emerged from the domination of the Asclepiadae, or priests of Aesculapius, who had followed it as an hereditary and secret art. Prior to this time in the numerous Asclepia, or Temples of Aesculapius, votive offerings had been accepted, some of which were of anatomical interest. Thus the Temple at Athens received a silver heart and gold eyes. Pausanias states that Hippocrates gave to the Temple of Apollo, at Delphos, a skeleton which was made of brass. Possibly, as Moehsen[2] believes, this was a metallic figure representing a man who was much emaciated by the ravages of disease. In the Hippocratic writings, some of which are undoubtedly spurious, are few references to the opening of a dead body; and these examinations concern the investigation of the thorax and abdomen in order to determine the cause of death. While the Greek physicians knew little of the human muscles, of the nervous system and of the organs of sense, they were well acquainted with the anatomy of the bones. Their dissections were held upon the lower animals.

It is impossible to determine whether or not the Greek physicians of the Hippocratic period dissected the human body. “It has long been a matter of debate”, says John Bell[3], “whether the ancients were, or were not, acquainted with anatomy, and the subject, with its various bearings, has been much and keenly agitated by the learned. If anatomy had been much known to the ancients, their knowledge would not have remained a subject of speculation. We should have had evidence of it in their works; but, on the contrary, we find Hippocrates spending his time in idle prognostics, and dissecting apes, to discover the seat of the bile.”

Galen[4] states that the ancient physicians did not write works on anatomy; that such treatises were at that time unnecessary, because the Asclepiadae—to which family Hippocrates belonged—secretly instructed their young men in this subject; and that opportunities were given for such study in the temples of Aesculapius.

ARISTOTLE

The first systematic dissections seem to have been made by the Pythagorean philosopher Alcmaeon, who lived in the sixth century B. C., but it is uncertain whether he dissected brutes or men. The cochlea of the ear and the amnios of the foetus were named by Empedocles of Agrigentum, in the fifth century B. C. The nerves were first distinguished from the tendons by Aristotle, (384-322 B. C.), the most celebrated zoötomist of antiquity, who has been called the Father of Comparative Anatomy. For twenty centuries his views of natural phenomena were held in high esteem.

For a long period the early inhabitants of Rome were practically without physicians. During severe epidemics they had recourse to oracles, to the health deities of the Greeks, and to their native gods. As early as the fifth century B. C., during a pestilence, a temple was erected to Apollo as Healer. The worship of Aesculapius was introduced into Rome in the year 291 B. C. Livy relates that the god of medicine in the guise of a serpent was transported from Epidaurus, in Greece, to the Isle of the Tiber where a temple was built in his honor.

The Romans, like the Greeks, were accustomed to leave votive offerings, or donaria, in their temples. Such gifts included surgical instruments, pharmaceutical appliances, painted tablets representing miraculous cures, and great numbers of images of various parts of the human frame shaped in metal, stone or terra-cotta. Among the remains of Roman anatomical art is the marble figure which was unearthed in the villa of Antonius Musa, the favorite physician of the Emperor Augustus. It is a human torso; the front of the chest and abdomen has been removed so as to expose the viscera. The heart is placed vertically in the middle of the thorax, thus corresponding to the position of this organ as described by Galen who made his dissections on apes. It is a human thorax with simian contents. The figure is supposed to have been constructed for the purposes of a teacher of anatomy.

ALEXANDER THE GREAT

It was in the famous Alexandrian University that human anatomy was first studied systematically and legally.

Alexander the Great, after the fall of Tyre (332 B. C.) and the siege of Gaza, ordered his fleet to sail up the Nile as far as Memphis while he proceeded overland with the army. It was probably on this march, while viewing the pyramids and other marvelous works of the ancient Egyptians, that he conceived the grand idea of founding a city upon the banks of the Nile, which should be a model of architectural beauty, a centre of intellectual life and a lasting monument of his own greatness and magnificence. The foundation of Alexandria was laid by the warrior whose name it bears; but the credit of instituting the Library belongs to one of his lieutenants, Ptolemy Soter.

PTOLEMY SOTER

The new city which for centuries was the intellectual and commercial storehouse of Europe, Africa and India, was of oblong form. Lake Mareotis washed its walls on the south, while the Mediterranean bathed its ramparts on the north. Provided with broad streets, it was adorned with magnificent houses, temples and public buildings. At the centre of the city was the Mausoleum in which was deposited the body of Alexander, embalmed after the manner of the Egyptians. Alexandria was divided into three parts: the Regio Judaeorum or Jews’ quarter, in the northwest; the Rhacotis, or Egyptian section, on the west, containing the Serapeum with a large part of the Library; and on the north, the Bruchaeum, or Greek portion, containing the greater part of the Library, the Museum, the Temple of the Caesars and the Court of Justice. The population was cosmopolitan in character; the statues of the Greek gods stood by the side of those of Osiris and of Isis; the Jews forgot their language and spoke Greek; and under the Ptolemies, who were of Greek descent, Alexandria became a centre of intellectual life and culture.

To the medical historian the most interesting feature of Alexandria was the Museum or University. Here were assembled the intellectual giants of the earth: Archimedes and Hero, the philosophers; Apelles, the painter; Hipparchus and Ptolemy, the astronomers; Euclid, the geometer; Eratosthenes and Strabo, the geographers; Manetho, the historian; Aristophanes, the rhetorician; Theocritus and Callimichus, the poets; and Erasistratus and Herophilus, the anatomists, all of whom labored in quiet upon the peaceful banks of the Nile. The early Christian church drew from “the divine school at Alexandria” such eminent teachers as Origen and Athanasius. Here were a chemical laboratory, a botanical and zoölogical garden, an astronomical observatory, a great library, and a room for the dissection of the dead.

In the Alexandrian school of medicine Erasistratus and Herophilus taught the science of organization from actual dissections. The generosity of the Ptolemies not only furnished them with an abundance of dead material, but condemned malefactors were used for human vivisection. Celsus[5] states that the Alexandrian anatomists obtained criminals, “for dissection alive, and contemplated, even while they breathed, those parts which nature had before concealed.”

Herophilus made many anatomical discoveries. He traced the delicate arachnoid membrane into the ventricles of the brain, which he held to be the seat of the soul; and first described that junction of the six cerebral sinuses opposite the occipital protuberance, which to this day is called the torcular Herophili. He saw the lacteals, but knew not their use, and regarded the nerves as organs of sensation arising from the brain; he described the different tunics of the eye, giving them names which are still retained; and first named the duodenum and discovered the epididymis. He attributed the pulsation of arteries to the action of the heart; the paralysis of muscles to an affection of the nerves; and first named the furrow in the fourth cerebral ventricle, calling it calamus scriptorius.

Erasistratus gave names to the auricles of the heart; declared that the veins were blood-vessels; and the arteries, from being found empty after death, were air-vessels. He believed that the purpose of respiration was to fill the arteries with air; the air distended the arteries, made them beat, and in this manner the pulse was produced. When once the air gained entrance to the left ventricle, it became the vital spirits. The function of the veins was to carry blood to the extremities. He is said to have had a vague idea of the division of nerves into nerves of sensation and of motion; to the former he assigned an origin in the membranes of the brain, while the latter proceeded from the cerebral substance itself. He recognized the use of the trachea as the tube which conveys air to the lungs. A catheter, the first invented, which was figured in ancient surgical works, bore the name of the catheter of Erasistratus. He gravely tells us, as the result of his anatomical studies, that the soul is located in the membranes of the brain.

The practice of human dissection did not long exist in the city of its origin, and after the second century was unknown. Then science underwent a retrogression; observations and experiments were replaced by useless discussions and subtle theories. The decline of the Alexandrian University was due to a series of disasters which began with the Roman domination and reached their climax with the capture of the city by the Arabs.

GALEN

Claudius Galenus, the celebrated Roman physician whose writings were for centuries accepted as authority and whose reputation was second only to that of Hippocrates, was obliged to base his anatomical treatises largely upon the dissection of the lower animals. He advised his pupils to visit Alexandria, where he had studied, in order that they might examine the human skeleton. He complained that the physicians of his time—in the reign of Marcus Aurelius—had entirely neglected anatomical knowledge and had degenerated into mere sophists. He appreciated the importance of anatomy, particularly to a surgeon who is called upon to treat wounds and injuries. Hence he has endeavored in the four books, De Anatomicis Administrationibus, to cover this part of anatomy as exhaustively as possible.

Galen’s voluminous writings form a precious monument of ancient medicine. The works of the Alexandrian anatomists having been destroyed, we know of their labors chiefly from what Galen has said of them. His treatises show a remarkable familiarity with practical anatomy, although his dissections were made upon the lower animals. Galen’s knowledge of osteology was extensive. He described the bones of the skull, the cranial sutures, and the essential features of the malar, maxillary, ethmoid and sphenoid bones. He divided the vertebrae into cervical, dorsal and lumbar classes. He knew that both arteries and veins were blood-carrying vessels; he described the valves of the heart, and recognized this organ as the source of pulsation. He erroneously taught that the interventricular septum presents foramina through which the two kinds of blood become mixed.

In myology Galen made numerous advances. “Previous to his investigations”, says Fisher[6] “much confusion existed as to what constituted a single muscle; he adopted the general rule of considering each bundle of fibers that terminates in an independent tendon to be one muscle. He was the first to describe and give names to the platysma myoides, the sterno- and thyro-hyoides, and the popliteal. He described the six muscles of the eye, two muscles of the eyelids, and four pairs of muscles of the lower jaw—the temporal to raise, the masseter to draw to one side, and two depressors, corresponding to the digastric and internal pterygoid muscles. He described also the brachialis anticus, the biceps flexor cubiti, the sphincter and levator ani, and the straight and oblique muscles of the abdomen. In short, he described the greater portion of the muscles of the body, his treatise differing chiefly from a modern one in the minute account of these organs and in the omission of some of the smaller muscles.” Galen studied the brain and named the corpus callosum, the septum lucidum, the corpora quadrigemina and the fornix; but erroneously stated that the nerves of sensation arise from the brain, and those of motion from the spinal cord. He denied the decussation of the optic nerves. He described the pneumogastric and sympathetic nerves; seven pairs of cerebral and thirty pairs of spinal nerves; and claimed the discovery of the ganglia of the nervous system. He located the seat of the soul in the brain, which also is the source of the rational mind; the heart to him was the source of courage and of anger, and the liver was the seat of desire. Many of Galen’s anatomical statements show that he derived his knowledge from comparative dissections.

The Galenic era was followed by that long period of ignorance, of slumber and of inaction which is justly known as the Dark Ages. While a few Greek and Arab writers, who came after Galen, contributed to the literature of medicine and surgery, they did nothing for anatomy. After the end of the fifth century even the works of Galen were forgotten. At this period, when medicine was chiefly in the hands of the Jews, the Arabs and the bigoted clergy, nothing was done for science or for art. The whole influence of Christianity was exerted against the schools of philosophy. Illustrious apostles of the Church pronounced anathemas against the reading of the ancient classics;[7] and eminent ecclesiastics regarded disease as a divine penalty or as an invaluable aid to saintly advancement. Art and anatomy were practically forgotten. Their Renaissance occurred almost simultaneously.

During the period from the seventh to the fourteenth centuries the school of Salernum was for medicine what Bologna became for law and Paris for philosophy. Here, for eight hundred years, medicine was taught to thousands of students and the impress of the profession was so potent that the city called itself Civitas Hippocratica, and thus its seals were stamped. Here medical diplomas were first issued to waiting students who took a sacred oath to serve the poor without pay. Here with a book in his hand, a ring on his finger and a laurel wreath on his head, the candidate was kissed by each professor and was told to start upon his way. Here women were professors and vied with men in spreading the doctrines of our art.

For a period of several hundred years anatomy was taught at Salernum from dissections made upon pigs. Copho, one of the Salernian professors of the early part of the twelfth century, wrote a treatise, Anatomia Porci, which gives minute directions regarding the manner in which the animal is to be dissected. Another anatomical work of later date, written by a member of the Salernian faculty, is entitled Demonstratio Anatomica; it also deals only with comparative anatomy. In the thirteenth century (A. D. 1231) Frederick II., Emperor of Germany and King of the Two Sicilies, and the author of a treatise which contained a complete anatomy of the falcon, decreed that a human body should be anatomized at Salernum at least once in five years. Physicians and surgeons of the kingdom were required to be present at the dissection. So far as is known, no record has been kept of these demonstrations. Creditable as was this anatomic decree, the great Hohenstaufen in other respects was not free from the errors of his age. A firm believer in Medicina Astrologica, he did not decide upon any undertaking until the stars had been consulted.

It was not alone at Salernum that dissection was legalized in the thirteenth century. A document of the year 1308, of the Maggiore Consiglio of Venice, shows that a medical college located in that city was authorized to dissect a body once a year. This, and other isolated examples, indicate that the time was approaching when anatomy should be taught from human dissections. The credit of reinaugurating the teaching of this useful department of science belongs to Mondino dei Luzzi of Bologna.

CHAPTER SECOND
Mondino, the Restorer of Anatomy

In the year 1315, in the old Italian city of Bologna, an event occurred which marks an important epoch in the history of medicine. A wondering crowd of medical students witnessed the dissection of a human cadaver—one of the few procedures of the kind that had occurred since the fall of the Alexandrian University. Acting under royal authority Mondino, a man far in advance of the age, placed the body of a female upon a table where for many centuries before only the cadavera of apes, of swine and of dogs had been studied.

Mondino, known also as Mundinus, Mundini, Raimondino, or Mondino dei Luzzi, was descended from a prominent Italian family. Little is known of his life. The year of his birth is disputed; probably 1276 was near the time. He was graduated in medicine in 1290 and in 1306 he became a professor in the University of Bologna, holding his chair with credit until his death in 1326. Like that of the illustrious Homer, Mondino’s nativity has been claimed by several rival cities. Guy de Chauliac, writing in 1363, states that Mondino was a Bolognese: Mundinus Bononiensis is Chauliac’s expression.

Mondino’s method of teaching anatomy is known from Chauliac’s testimony:—“Mundinus of Bologna, wrote on anatomy, and my master, Bertruccius, demonstrated it many times in this manner:—The body having been placed on a table, he would make from it four readings; in the first the digestive organs were treated, because more prone to rapid decomposition; in the second, the organs of respiration; in the third, the organs of circulation; in the fourth the extremities were treated.” The innovation so auspiciously begun was not continued, and after the death of Mondino human dissections were made only at long intervals. The few instances in which, in the fourteenth and fifteenth centuries, the ecclesiastical and civil authorities granted the right to make dissections only prove the contention, that the practical study of human anatomy did not gain recognition until the sixteenth century.

When Mondino began his dissections the epoch of Saracen learning had ended, but the influence of Arab medicine exerted by the writings of Albucasis, Avicenna and Rhazes had not declined. The Arabian physicians had accomplished little for anatomy. In this line the influence of Galen was still potent, and was rarely questioned until the publication of the Fabrica of Vesalius in 1543. During a long period the little treatise of Mondino held full sway in the mediaeval schools. Medicine was taught in the University of Bologna, which as early as the twelfth century was celebrated for its departments of literature and of law. These studies were free of the difficulties which beset medicine. The prejudice against dissection was so great that for nearly a century after his death few men dared to repeat the acts of Mondino.

In 1316 Mondino issued his book which remained in manuscript form for more than one hundred and fifty years, the first printed edition bearing the date 1478. Small and imperfect as it was, it marks an era in the history of science. By command of the authorities this book was read in all the Italian Universities. The work of Mondino contained no new facts; it was compiled largely from the writings of Galen and of Avicenna. The descriptions, to use the words of Turner, “are corrupted by the barbarous leaven of the Arabian schools, and his Latin is defaced by the exotic nomenclature of Ibn-Sina and Al-Rasi”. Mondino divided the body into three cavities, of which the upper contains the animal members, the lower the natural members, and the middle the spiritual members. Many of his names are borrowed from the Arab writers. Thus, he calls the peritoneum siphac, the omentum zyrbi, and the mesentery eucharus. His description of the heart is much nearer accuracy than would be expected. He resorted to vivisection, and tells us that when the recurrent nerves of the larynx are cut the animal’s voice is lost. In his book we find the rudiments of phrenology. He states that the brain is divided into compartments, each of which holds one of the faculties of the intellect.

MONDINO’S DIAGRAM OF THE HEART, 1513

Mondino did not himself make the dissections which are credited to him. According to an ancient custom which lasted until the time of Vesalius, the actual cutting was done by a barber who wielded a knife as large as a cleaver. The professor of anatomy sat upon an elevated seat and discoursed concerning the parts, while a demonstrator, who also did not soil his fingers, pointed to the different structures with a staff. Originally Mondino’s book contained no figures; when the art of wood engraving was introduced in the latter part of the fifteenth century, a few rude woodcuts appeared which represent Mondino and his method of teaching. In the Fasciculus Medicinae of Joannes de Ketham, published at Venice in 1493, Mondino’s book is printed with an illustration showing a demonstration in anatomy.

According to Mondino the heart is placed in the centre of the body. The valves he considers “wonderful works of nature”. He describes a right, left and middle ventricle. The right ventricle has thinner walls than the left, because it contains blood; the left one contains the vital spirit, which passes through the arteries to the body; and the middle ventricle consists of many small cavities “broader on the right side than on the left, to the end that the blood, which comes to the left ventricle from the right, be refined, because its refinement is the preparation for the generation of vital spirit, which should be continually formed”. Mondino describes five bones of the head, separated by three sutures—coronal, sagittal and occipital. The brain has two membranes: dura and pia. There are three cerebral ventricles—anterior, posterior and middle—and in these he locates the various intellectual qualities. He describes the cerebral nerves: olfactory, optic, motor oculi, facial, vagus, trigeminal, auditory and hypoglossal. He calls the innominate bone os femoris: the femur, canna coxae; the humerus, os adjutori; while the bones of both leg and forearm are named focilia major and minus.

ANATOMICAL DEMONSTRATION IN 1493
(Joannes de Ketham)

TITLE-PAGE OF MONDINO’S ANATOMY BY MELERSTAT
(Printed before 1500)

Like many anatomists who succeeded him, Mondino mingled surgical ideas with his anatomical statements. A break in the siphac causes hernia and a swelling in the mirach. He treated ascites by puncture and evacuation, making a valve-like opening. Wounds of the large intestines must be sutured; if the wound be in the small intestines he advises that “you should have large ants, and, making them bite the conjoined lips of the wound, decapitate them instantly, and continue until the lips remain in apposition and then reduce the gut as before”. He gives an explanation of the length and convolution of the intestines; “for if it were not convoluted the animals would have to be continuously ingesting food and continuously defecating, which would impede engagement in the higher occupations”. Digestion is aided by black bile from the spleen and by red bile from the liver. The kidneys he regards as glands in which urine is extracted from the blood. The renal veins expand and form a fine membrane like a sieve through which the urine is filtered but blood cannot pass. He mentions renal calculi: if small they pass through the ureter; if large they are incurable except by incision, and this is to be avoided. The uterus and breasts are connected by veins, hence the sympathy between these organs. Inguinal hernia is to be operated upon; the spermatic cord and testicle may or may not be dissected out, or the hernia may be treated by the application of a caustic. An incision in the neck of the bladder will heal, because this part is muscular; but a cut in the body of the organ will not heal. He describes the operation for stone:—The patient being in proper position, the stone is conducted to the neck of the bladder by the finger in the rectum; an incision is made and the stone is pulled out with an instrument called trajectorium.

Mondino’s book passed through not less than twenty-three editions between the years 1478-1580. The only manuscript extant is in the National Library at Paris.

The first printed edition of the Anathomia Mundini, Pavia, 1478, is a folio of twenty-two leaves. The Strassburg edition, 1513, is a small octavo volume of forty leaves. It contains a diagram of the heart and an astrological figure, a cadaver with the thorax and abdomen opened, surrounded by the signs of the zodiac. Such was the volume which for more than two hundred years was supposed to contain all that was to be said of human anatomy!

COLOPHON OF THE ANATOMY OF MONDINO, 1513

So numerous are the abbreviations in Mondino’s book, so barbarous is his style, that the making of a translation is a difficult task. His reasons for writing are these:—“A work upon any science or art—as saith Galen—is issued for three reasons; First, that one may help his friends. Second, that he may exercise his best mental powers. Third, that he may be saved from the oblivion incident to old age”.

CHAPTER THIRD
Mondino’s Successors

For two hundred years anatomists used Mondino’s book as a text for their lectures and for the same period anatomical writers did little more than comment upon this treatise. The new art of wood engraving was turned to anatomical use and crude illustrations of the various parts of the body were put into circulation. Some of these pictures were in the form of Fliegende Blätter, or flying leaves. A set of anatomical plates of this type was issued by a certain Ricardus Hela, a physician of Paris, as early as the year 1493. They were printed at Nuremberg. Their character may be judged by the accompanying illustration of the osseous system.