The Greatest Benefit to Mankind: A Medical History of Humanity

Thereafter Vesalius grew more critical. Familiarity with human anatomy drove him to the unsettling conclusion that Galen had dissected only animals, and forced him to see that animal anatomy was no substitute for human. He now began to challenge the master on points of detail: for instance, the lower jaw comprised a single bone not two, as Galen, relying on animals, had stated. Evidently, human anatomy had to be learned from dead bodies not dead languages.

In 1539 he acquired a larger supply of cadavers of executed criminals and worked on his great masterpiece, the De humani corporis fabrica. Finishing it in 1542, he took it to Basel where the press of Joannes Oporinus published it in 1543 as one of the pearls of Renaissance printing. It presents exact descriptions of the skeleton and muscles, the nervous system, blood vessels and viscera. Though it contains no shattering discoveries, it marks a watershed in the medical understanding of bodily structures, for Vesalius interrogated Galen by reference to the human corpse. Others had criticized odds and ends of Galenic anatomy, but Vesalius was the first to do this systematically. The Fabrica gained immensely from the contribution of the artist, Jan Stephan van Calcar (1499–c. 1546), also from the Netherlands, who provided the text with technically accurate drawings displaying the dissected body in graceful lifelike poses. The work also enunciated clear methodological principles: the anatomist-lecturer must perform the dissection himself, the eye was preferable to authority, and anatomy was the skeleton key to medicine.

Book I of the Fabrica began in Galenic fashion with the bones rather than the internal organs. Various Galenic lapses were corrected: for example, the human sternum has three, not seven, segments. Book II dealt with the muscles and included the famous suite of illustrations showing ‘muscle-men’ at different stages of corporeal ‘undress’. Book III, on the vascular system, was less accurate because Vesalius still based his descriptions partly on animal material. Book IV described the nervous system, following the Galenic classification of the cranial nerves into seven pairs.

Book V dealt with the abdominal and reproductive organs, where he corrected Galen’s belief in the five-lobed human liver. He nevertheless still accepted the Galenic physiological tenet that the liver produced blood from chyle, while denying that the vena cava originated in the liver – an observation which, had Vesalius been more physiologically-minded, might have begun the erosion of the Galenic belief in two distinct vascular systems, the venous originating in the liver and the arterial stemming from the heart.

Book VI was devoted to the thorax. Examining the heart, Vesalius cast doubt on the permeability of the interventricular septum: ‘We are driven to wonder at the handiwork of the Almighty by means of which the blood sweats from the right into the left ventricle through passages which escape the human vision.’ In the second edition (1555), this implicit denial of the septum’s permeability was made direct. Here lay a milestone of Renaissance anatomy, for it encouraged anatomists like Realdo Colombo (c. 1515–59) to conceive of the pulmonary transit, later used by William Harvey as evidence of the circulation of the blood. Another crucial correction of Galen came in Book VII, on the brain, where Vesalius denied the existence of the rete mirabile in humans.

In the end, Vesalius’s importance lay in daring to think the unthinkable: that Galen might actually be wrong, and Galen worship with it:

How much has been attributed to Galen, easily leader of the professors of dissection, by those physicians and anatomists who have followed him, and often against reason! … Indeed, I myself cannot wonder enough at my own stupidity and too great trust in the writings of Galen and other anatomists.

The Fabrica thus laid the groundwork for observation-based anatomy, announcing a new principle of fact-finding and truth-testing: all anatomical statements were to be subjected to the test of human cadavers.

Later anatomists corrected Vesalius as he had corrected Galen, and independent observation thus became sovereign. Anatomists also grew impatient to establish personal priority in discovering new structures. Amerigo Vespucci had his name immortalized in a continent; for an anatomist, naming a bodily part could be crucial for making his name.*

The frontispiece of the Fabrica presents the dreams, the programme, the agenda, of the new medicine. The cadaver is the central figure. Its abdomen has been opened so that everyone can peer in; it is as if death itself had been put on display. A faceless skeleton points towards the open abdomen. Then there is Vesalius, who looks out as if extending an invitation to anatomy. Medicine would thenceforth be about looking inside bodies for the truth of disease. The violation of the body would be the revelation of its truth.

By transference, the idea of anatomizing became a potent medical metaphor during the next couple of centuries, as in Robert Burton’s Anatomy of Melancholy (1621) or John Donne’s poem ‘An Anatomy of the World’ (1611), and modern medicine adopted the anatomy lesson as its signature: medicine was represented as a probe into nature’s secrets, peeling away layer upon layer in the hunt for truth; nothing would resist its gaze. The knife also suggested other modes of mastery, not least sexual conquest, as when Donne likens the lover’s caress to a surgeon’s knife:

And such in searching wounds the surgeon is

As wee, when wee embrace, or touch, or kiss.

A new genre came into fashion: self-anatomy, introspection into one’s own soul, a kind of spiritual or psychological dissection. ‘I have cut up mine owne Anatomy,’ declared Donne, ‘dissected myselfe, and they are got to read upon me.’

Practical anatomy advanced on a broad front after the Fabrica. Accounts of the whole body continued to be published, for instance Charles Estienne’s (1504–64) De dissectione partium corporis humani (1545) [On the Dissection of the Human Body]. Realdo Colombo, an apothecary’s son who studied surgery at Padua, succeeding Vesalius there in 1544, corrected some of his errors in his De re anatomica [On Anatomy], published posthumously in 1559. He accused Vesalius of passing off descriptions of animal anatomy as human – precisely Vesalius’s charge against Galen. Colombo’s discovery of the pulmonary transit and elucidation of the heartbeat were momentous. Vivisection experiments showed that blood went from the right side of the heart through the lungs to the left side; that the pulmonary vein did not, as Galen had thought, contain air but blood; and that blood was mixed with air not in the left ventricle of the heart but in the lungs, where it took on the bright red hue of arterial blood. Describing the heartbeat, Colombo held, opposing former views, that the heart acted with greater force in systole (contraction) than in diastole (dilation); this too was crucial for Harvey.

Gabriele Falloppia (1523–63) was appointed in 1551 to perform the annual anatomies at Padua, and he produced more criticism of the Fabrica in his Observationes anatomicae (1561) [Anatomical Observations]. The tremendous kudos of the new anatomical teaching is illustrated by an incident in 1555, when the university authorities sought to revive the old style of anatomizing as ordained by the statutes. A junior lecturer was to read out Mondino’s Anatomia, and the senior professor, Vettor Trincavella (1490–1563), was to deliver theoretical lectures. Falloppia’s role as anatomist would thereby have been demeaned. In the event, Trincavella’s orations were broken up by rowdy students chanting vogliamo il Falloppio (‘we want Falloppia’), after which anatomy was entirely in his hands.

Falloppia’s Observationes may be regarded as a coda to the Fabrica, adding new observations and correcting errors in both Galenic and Visalia anatomy. Though not a systematic textbook, it covered a wide range of subjects, with emphasis on the skeleton, especially the skull, and the muscles. Particularly important were his descriptions of the structure of the inner ear, the carotid arteries, the head and neck muscles, and the orbital muscles of the eye. It also contains the famous description of the uterine tubes bearing his name. Falloppia meanwhile kept up a huge practice, claiming to have examined the genitals of 10,000 syphilitics.

Unlike Vesalius, later anatomists produced specialized studies of body parts, such as the treatises on the kidney, the ear and the venous system published by Bartolomeo Eustachio (c. 1500–74) in his Opusula anatomica (1564) [Anatomical Studies]. He scolded Vesalius for depicting a dog’s kidney instead of a human one, and produced figures of the ear ossicles and the tensor tympani in man and in dogs. The Eustachian tube from the throat to the middle ear was described, though priority really belonged to Giovanni Ingrassia (1510–80), who had discovered it in 1546.

Study of specific structures encouraged comparative anatomy, in which different animals were correlated in a self-consciously Aristotelian manner; Aristotle had been keen to compare animal anatomy for classification purposes and to discover essential structural/functional correlations. The greatest comparative anatomist was one of Falloppia’s pupils, Hieronymus Fabricius ab Aquapendente (Fabrizio or Fabrici: c. 1533–1619), who succeeded to his Padua chair in 1565. Fabricius’s aim was to produce a work to be called Totius animalis fabricae theatrum [The Theatre of the Entire Animal Structure], but only small sections emerged. As an anatomist he was less interested in Visalia structural architecture than a comparative approach which stressed three aspects of anatomy: the description, action, and use of body parts. Although Vesalius had surpassed the ancients in descriptive accuracy, he had written little on the action and use of the parts; this was what Fabricius aimed to remedy.

Fabricius’s most significant work was De venarum ostiolis (1603) [On the Valves of the Veins], for the venous valves were to be crucial for William Harvey’s demonstration of the blood circulation. It was not Fabricius who discovered them, but he was the first to discuss them at any length. The valves, he maintained, were designed to prevent the extremities from being flooded with blood and to ensure that the other body parts would get their fair share. This theory tallied with the Galenic view that blood was attracted from the liver, the blood-making organ, by each part of the body when it needed nourishment. The valves thus helped the central and upper parts to get blood by preventing its tendency to gather at the extremities.

Fabricius’s embryological treatises also influenced Harvey. De formatione ovi et pulli (1621) deals with the development of the egg and the generation of the chick, while De formatu foetu (1604) [On the Formation of the Foetus] describes how nature provides the means for foetal growth, nourishment and birth. His descriptions of foetal development lay within the Aristotelian theoretical framework of the female contributing the matter and the male the form.

A more idiosyncratic challenge to Galenic physiology had meanwhile come from the polymath Michael Servetus (1511–53). Sickened by the corruption of the Roman Church, Servetus went further than Luther along the road of heresy and developed anti-Trinitarian views, leading to condemnation by Catholics and Protestants alike. In Lyons he had met the medical humanist Symphorien Champier (c. 1471–1539), who advised him to study in Paris, where he worked with the cream of the faculty: Sylvius, Fernel and Guinther von Andernacht. But he soon fell under suspicion, and was condemned in 1538 by the Parlement of Paris for lecturing on astrology. In 1553 he anonymously published his major work, the 700-page Christianismi restitutio [The Restoration of Christianity], which was denounced by Calvin as heretical. Escaping the Inquisition, Servetus was nevertheless condemned for heresy on entering Calvin’s Geneva, and burnt at the stake.

It was in The Restoration of Christianity that Servetus announced the pulmonary transit of the blood, within the framework of an heretical account of how the Holy Spirit entered man. The Bible taught that the blood was the seat of the soul and that the soul was breathed into man by God: there had therefore to be a contact point between air and blood. This led Servetus to denounce Galen’s whole scheme. Blood did not go through the septum; he proposed instead a path from the right to the left heart through the lungs. Blood was mixed with air (that is, spirit) in the lungs, rather than in the left ventricle. Confirmation lay in the size of the pulmonary artery – its design was too large to transmit blood for the lungs alone. Servetus’s views had no influence on the development of anatomy, not least because almost all copies of his book were burnt with their author.

Renaissance dissections increased knowledge of the structure of man and other animals. But while precipitating an anti-Galen reaction, Vesalian anatomy followed his precepts: without Galen no Fabrica. Humanist anatomy was conservative in theory. No anatomist opposed the traditional Galenic tripartite division of physiologic function (venous, centered on the liver; arterial, centered on the heart; and sensory/motor, centered on the brain), even when anatomical structures and vascular connections crucial to the scheme were being discredited (for instance, the rete mirabile). For all their radical rhetoric, Vesalius’s generation shored up ancient medicine and philosophy even as they exposed its factual errors. All the same, Renaissance anatomists enormously elevated the standing of their subject. Its status had been low; it was not listed among the ancient major divisions of medicine, and was stigmatized by its surgical connexions; but the appointment of the physician Vesalius at Padua served notice that anatomy and surgery were to be incorporated into the wider humanist medical movement. The Fabrica’s preface argued for the unity of the different medical arts; physicians should not disdain to use their hands, an adage equally dear to contemporary experimental natural philosophers.

Anatomy became integrated into learned medicine – even in backward England, thanks to John Caius (1510–73). Caius was a Galenist physician and protégé of Thomas Linacre, who had been largely responsible for the founding of the College of Physicians in 1518, and for the medical lectureships at Oxford and Cambridge.

Educated at Gonville Hall in Cambridge, from 1539 Caius studied at Padua, teaching Greek and collecting manuscripts, particularly those of Galen, whom he idolized. On his return, he settled in the capital, being admitted Fellow of the College of Physicians in 1547. In his nine terms as president, Caius attempted to mould the college along continental lines, regulating medicine according to the best Galenic standards. He reorganized its statutes, and introduced formal anatomies into its lectures, also demonstrating anatomy before the Barber-Surgeons Company. In Cambridge he refounded his old hall in 1557 as Gonville and Caius College, serving as its master from 1559 and fostering a strong medical tradition, from which William Harvey (1578–1657) was to benefit. Through enthusiasts like Caius and his equivalent in Leiden, Pieter Pauw (1564–1617), anatomy became incorporated throughout Europe into the humanist revival.

Anatomists presented their subject as the cutting edge; the way to certain knowledge was through the senses, especially by ‘autopsia’, seeing for oneself. Though the Paduan Aristotelian philosopher Cesare Cremonini (1552–1631) was still insisting in 1627 that anatomy could never be the foundation of medicine (only causes, the domain of philosophy, and not observation could lead to certainty), the sheer success of anatomy swept this dogma aside. Dissections became public events: at Bologna they were staged during the annual carnival, the macabre fascination of the memento mori, juxtaposing life and death, contributing to the appeal. Rembrandt’s ‘The Anatomy Lesson of Dr Nicolaes Tulp’ (1632), shows that anatomy had become one of the spectacles and symbols of the age. Not only the method of medicine, anatomy became accepted as a window onto the human condition.

SURGERY

Surgery saw fewer significant changes, and still played second fiddle to physic, being relatively unaffected by the new anatomy. Restricted largely to the body’s surface, surgeons dealt with the many accidents of life. They set fractures, treated burns, contusions, knife wounds and the increasingly common gunshot wounds, tumours and swellings, ulcers and various skin diseases; syphilis was usually handled as a surgical condition. Surgery was seen as a skilled craft: ‘A chirurgien should have three divers properties in his person,’ judged John Halle (1529–68), ‘that is to say, a heart as the heart of a lion, his eye like the eyes of an hawk, and his hands as the hands of a woman.’

Through most of Europe, surgery continued to be taught by apprenticeship and organized in guilds. In London a master surgeons’ guild had been founded in 1368; the Mystery or Guild of the Barbers of London received its charter from Edward IV in 1462; and in 1540, by Act of Parliament, the Guild of Surgeons merged with the Barbers to form the Barber-Surgeons Company, its first master being Thomas Vicary (c. 1490–1561); Holbein painted Henry VIII chartering the company, which continued until 1745. An active member was William Clowes (1544–1603), who worked as a naval surgeon before setting up in practice in London and being appointed surgeon at St Bartholomew’s Hospital in 1575. Military operations in the Low Countries (1586) gave him ample experience, and in 1588 he was appointed surgeon to the fleet. Clowes’s treatises on wounds, venereal disease and scrofula were written in racy vernacular, with young surgeons in mind, presenting personal case histories.

Clowes was one of a line of able common-or-garden surgeons: John Woodall’s (1556–1643) The Surgeon’s Mate (1617) served as a manual of naval surgery, attacking the bad habits of ‘blaspheming the name of the Almighty’ and the ‘dedication to the pot and Tobacco-pipe’ which were all too common among apprentices; Richard Wiseman (1621–76) was honoured as the ‘father of English surgery’. His Several Chirurgical Treatises (1676) dwelt on military and naval problems, while his Treatise of Wounds (16 j 2), jocularly known as Wiseman’s Book of Martyrs, advertised itself as specially for ships’ doctors ‘who seldom burden their cabin with many books’. He picked up much of his experience during the English Civil War, and his account of military surgery reveals its horrors: cannonballs and gunshot caused horrifying wounds, and amputation and trepanation were often the only remedies, conducted on the battlefield or on a storm-tossed vessel.

Fabricius left a graphic description of a sixteenth-century amputation:

I was about to cut off the thigh of a man of forty yeares of age, and ready to use the saw, and Cauteries. For the sick man no sooner began to roare out, but all ranne away, except only my eldest Sonne, who was then but little, and to whom I had committed the holding of his thigh, for forme only; and but that my wife then great with child, came running out of the next chamber, and clapt hold of the Patient’s Thorax, both he and myselfe had been in extreme danger.

This may not have been an uncommon scene before anaesthesia was available.

‘He who wishes to be a surgeon should go to war,’ Hippocrates had advised, and the battlefield became accepted as the school of surgery. Growing use of gunpowder had worsened the injuries confronting field-surgeons, because cannonballs and lead shot destroyed far more tissue than arrows or swords and left gaping wounds prone to infection. Many of the most popular vernacular handbooks, such as the Buch der Wund-Artzney (1497) [Book of Wound Dressing] of Hieronymus Brunschwig (1450–1533) and the Feldbuch der Wundartzney (1517) [Fieldbook of Wound Dressing] of Hans von Gersdorff (c. 1455–1529), were based on field experience. Brunschwig’s work contains the earliest printed illustrations of surgical instruments, and endorsed the view that shot wounds were poisoned by gunpowder and so required cautery. Gersdorff explained how to extract bullets with special instruments and dress wounds with hot oil. Amputated stumps were to be enclosed in an animal bladder, after controlling haemorrhage by pressure and styptics. Thomas Gale (1507–87) published An Excellent Treatise of Wounds made with Gonneshot (1563) – the first English work on the subject.

The most acclaimed Renaissance surgeon, Ambroise Paré (1510–90), also learned his craft through war. In 1533 he served as aide-chirurgien to the chief Paris hospital, the Hôtel Dieu; and from 1537, for almost thirty years, he divided his time between tending the Paris sick and following the army. Enrolled in 1554 into the confraternity of St Côme, the surgeons’ college, five years later Paré attempted in vain to save the life of Henri II after he had been wounded in a jousting tournament.

Paré gave a conventional account of the ‘five duties’ of his art: ‘to remove what is superfluous, to restore what has been dislocated, to separate what has grown together, to reunite what has been divided and to redress the defects of nature’. His prime innovation lay in rejection of the standard treatments for gunshot wounds: the use of cautery (the burning iron) or scalding oil (‘potential cautery’) to destroy poison and forestall putrefaction before beginning restorative therapy. In his La methode de traicter leys playes faictes par hacquebutes et aultres bastons à feu (1545) [Treatise on Gunshot Wounds], he described how, as a greenhorn on campaign in Italy in 1537, he had been forced to innovate. Initially, as taught, he had used boiling oil on what were considered to be poisonous gunpowder wounds:

But my oil ran out and I had to apply a healing salve made of egg-white, rose-oil and turpentine. The next night I slept badly, plagued by the thought that I would find the men dead whose wounds I had failed to burn, so I got up early to visit them. To my great surprise, those treated with salve felt little pain, showed no inflammation or swelling, and had passed the night rather calmly – while the ones on which seething oil had been used lay in high fever with aches, swelling and inflammation around the wound.

At this, I resolved never again cruelly to burn poor people who had suffered shot wounds.

Thenceforth he relied on restorative methods, using a digestive (wound-dressing) made of egg, oil of roses and turpentine, justifying this on the supposition that the gunpowder and shot were not, after all, poisonous. Piously, he always said that he had dressed the wound but God had healed the patient: Je le pansay; Dieu le guarit.

Another innovation mentioned in his Dix livres de la chirurgie (1564) [Ten Books of Surgery] was the use of ligatures in conducting amputations. Other writers had recommended tying off the veins and arteries so as to stop the blood, but Paré worked out the practical details. This made successful thigh amputations possible – William Clowes reported performing one in 1588, as did Fabricius a little later. There was, however, one drawback. No fewer than fifty-three ligatures were necessary in a thigh amputation, and this required trained assistance. Consequently, ligatures could come into general use only after a method had been found to control blood flow until the surgeon could tie the blood vessels, something accomplished in eighteenth-century France when J. L. Petit invented the first effective tourniquet.

Paré’s Cinq livres de chirurgie (1572) [Five Books of Surgery] dealt at length with fractures and dislocations, while in the Deux livres de chirurgie (1572) [Two Books of Surgery] he addressed the study of obstetrics, showing the art of podalic version (turning a baby in the womb, to facilitate feet-first delivery, as earlier described by Soranus) – and also seeking to explain monstrous births. His successes, however, did not go unchallenged. In 1575, the Paris faculty condemned him for publishing on ‘medical’ topics – an affront reflecting the tetchiness of physicians towards surgeons’ encroachments on their turf.