HISTORICAL VIGNETTES IN VASCULAR SURGERY Norman M. Rich, MD, Section Editor
The anatomist Andreas Vesalius at 500 years old Justin Barr, PhD, Charlottesville, Va
December 31, 2014 marked 500 years since the birth of Andreas Vesalius. Praised by contemporaries and lauded by generations since as the most important anatomist in western history, he fundamentally reshaped the discipline, made numerous anatomical discoveries, and most importantly, advanced the trajectory of modern medicine by rejecting textual dependence in favor of personal observation. This article, commemorating Andreas Vesalius and his accomplishments on the 500th anniversary of his birth, will first provide a brief biography of the man. It then discusses his role as the “Father of Anatomy” and his influence in transforming the study of the human body. Finally, it highlights Vesalius’ specific contributions to vascular anatomy and physiology. A PORTRAIT OF THE MAN Andreas Vesalius (née Andries van Wesel) was born in Brussels in 1514.1,2 The son of an imperial pharmacist, he grew up in Flanders, although little is known about his early life. As an undergraduate at the University of Louvain (1529-1533), he gained the linguistic skills and humanist outlook that enabled his meteoric career. From 1533 to 1536, Vesalius studied medicine at the University of Paris, which at that time dogmatically taught the ideas of Galen. While in France, he took lessons from Jacobus Sylvius, an ardent Galenist and famous physician in his own right, who later came to oppose bitterly his student’s anatomical discoveries that denied the preeminence of the ancients. War between France and the Hapsburg Empire rendered Vesalius a persona non grata in Paris, and he completed his licentiate in medicine at Louvain in 1573, writing his thesis on the famous Arabic physician Rhazes. He transferred to the University of Paduadthe premier medical university of the eradto complete his doctorate.3 The day after graduating in 1538, he assumed the Chair of the Department of Surgery. From the School of Medicine, University of Virginia. Author conflict of interest: none. Reprint requests: Justin Barr, PhD, University of Virginia School of Medicine, PO Box 800793, Charlottesville, VA 22908 (e-mail: justbarr@gmail. com or [email protected] or [email protected]). The editors and reviewers of this article have no relevant financial relationships to disclose per the JVS policy that requires reviewers to decline review of any manuscript for which they may have a conflict of interest. J Vasc Surg 2015;61:1370-4 0741-5214 Copyright Ó 2015 by the Society for Vascular Surgery. Published by Elsevier Inc. http://dx.doi.org/10.1016/j.jvs.2014.11.080
1370
As Professor of Surgery, Vesalius educated the medical students in anatomy, a subject he preferred over clinical practice. Uniquely for the era, Vesalius insisted on the importance of actual dissection, by both teacher and pupil, when learning anatomy. His position afforded him time to study the human body and resulted in several publications, including his 1543 masterpiece Fabrica (discussed below). He dedicated and presented his book to Emperor Charles V, who subsequently appointed Vesalius to the Royal Court as medicus familiaris ordinarius, a position he retained until Charles’ abdication in 1556. Vesalius functioned largely as a military surgeon while Charles embarked on a series of campaigns through Europe. In this capacity, he, along with his contemporary, Ambroise Paré, assisted in the treatment of King Henri II’s lance wound to the head (and subsequent autopsy). Upon Charles’ abdication, Vesalius continued to serve the Hapsburgs in Spain, although he became deeply dissatisfied with his position there. In the 1560s, he went on a pilgrimage to the Holy Land. A storm waylaid his ship on the return voyage, and Vesalius died on the Mediterranean island of Zante in 1564.1,2 VESALIUS THE ANATOMIST Vesalius entered a medical world newly interested in the study of anatomy, and he totally transformed the discipline. In the beginning of the 16th century, Galen’s writings dominated the study of the human body. Cultural taboos prevented Galen from dissecting human bodies, forcing him to rely on animalsda deficiency he candidly acknowledged and one that led to numerous errors. Human dissection began in Europe as early as 1286 and had spread throughout the continent in the 1300s. Despite suggestions otherwise, the Catholic Church never officially forbade the practice.4 However, surgeons and scientists charged with performing the necropsies looked to confirm the writings of Galen, much as medical students today approach cadavers with Grant’s or Netter’s Atlas at hand, rather than as investigators seeking to uncover new truths about the structure of the human body. Moreover, most medieval physicians, surgeons, and medical students refused to sully their own hands in the corpse, instead hiring assistants of lower social stature to perform the actual dissection (Fig 1). In 1316, Mondino da Luzzi wrote the first book dedicated to anatomy since antiquity, and although based almost entirely on Galen and Avicenna, it remained the standard text for the next two centuries. In 1521, Giacomo
JOURNAL OF VASCULAR SURGERY Volume 61, Number 5
Fig 1. A medieval anatomy lesson is portrayed in this painting from Johannes de Ketham’s Fascicolo di Medicina (1491). The professor is seated high above the body and directs the dissection, although he gazes at the viewer, not the corpse. The green-frocked man is actually performing the dissection. His waist-length garment distinguishes him as belonging to a lower social class. Medical students, in long red and black robes, gather around to observe. This image is in the public domain, scanned from a facsimile copy housed in the Historical Collections and Services of the Claude B. Moore Health Sciences Library at the University of Virginia and used with their permission.
Berengario de Carpi, Professor of Anatomy at the University of Bologna, published a new text that, at 1000 pages, began to modernize the discipline. Relying at least partially on human dissection, Berengario tentatively questioned the accuracy of the ancients while making a number of new observations. Perhaps more importantly, this text, along with Guinther von Andernach’s Latin translation of Galen’s Anatomical Procedures in 1531, sparked a revival in the science of anatomy just as Vesalius began his medical studies.1,2,5 In combination with the surge of interest in anatomy, Vesalius worked in the midst of the Renaissance, when artists, philosophers, scientists, and surgeons were all expanding the boundaries of knowledge. Tellingly, the same year Vesalius wrote Fabrica, his fellow Paduan alum, Copernicus, published his monumental work expositing the heliocentric model of the universe.6 This exciting intellectual
Barr 1371
Fig 2. Frontispiece of the original 1543 edition of Fabrica. The man performing the dissection is Vesalius. Notice that the cadaver is a womandincredibly rare for the era (Vesalius only dissected two in his career)dand is disproportionately larger than all the other humans in the picture. The three weasels at the top are the Vesalius family shield. The “IO” to its left are the initials of the publisher, Johannes Oporinus, whose likeness appears as the old man peering down from the balcony. The frontispiece is replete with symbolism. The dog and the chained monkey signify Galen’s dependence on animals for anatomy. The classically dressed figures are at the same level as Vesalius, demonstrating that modern medicine was equal to that of the ancients. (The man in Greek robes on the right staring at the dog is believed to be Realdo Colombo). The skeleton in the center highlights the importance of osseous anatomy, and the nude figure clinging to the column on the left signifies the salience of surface anatomy. Perhaps most significantly, the lithograph portrays Vesalius performing the dissection himself, in stark contrast to most of his predecessors and contemporaries (depicted in Fig 1) who would sit on high and dictate the anatomy as another, lower-class individual, actually exposed the assigned structures.7 This image is in the public domain. Scans of every plate in the first edition, including this frontispiece, are freely available from the National Library of Medicine at http://www.nlm.nih.gov/exhibition/ historicalanatomies/vesalius_home.html.
climate stimulated original investigation while simultaneously fostering an environment accepting of new knowledge that contradicted previously established doctrines. Vesalius began his anatomical studies shortly after assuming his Chair at Padua. Importantly, he personally
1372 Barr
JOURNAL OF VASCULAR SURGERY May 2015
Fig 3. Plates 44 and 45 of Fabrica. Left, Plate 44 displays the veins of the body and (right) plate 45 shows the arteries. The additional detail and attention in plate 44 indicate the importance of the veins over the arteries in the 16th century. As the images display and O’Malley and Saunders describe, Vesalius did not have a perfect grasp of vascular anatomy. In plate 44, the right renal vein is mistakenly superior to the left (a relationship more common in animals), the azygos is abnormally dilated, and the veins at the base of the neck follow a nonhuman mammalian pattern. The continuity of the vena cava reflected the contemporary understanding of the role of the atria (considered part of the vessel and not of the heart). In plate 45, the aortic arch appears as a bovine variant, the lateral thoracic artery is disproportionately large for humans, and the branches of the internal and external carotid arteries are confused.7 These picayune errors aside, Vesalius’ mapping of the vasculature was a quantum leap beyond anything previously produced and served as the standard reference point for generations of physicians. The images are in the public domain. Electronic images scanned with permission from the 1555 edition housed in the Historical Collections and Services of the Claude B. Moore Health Sciences Library at the University of Virginia.
dissected cadavers, and encouraged/forced his students to do the same. Bodies typically came from the gallows or fresh graves; the local magistrate courteously timed Padua’s executions around Vesalius’ needs. That he himself worked with the cadavers represented a significant departure from previous practice and ushered in an era when merely supervising anatomy no longer sufficed. It was this hands-on engagement that enabled Vesalius to master the subject and make his portentous discoveries. While a professor, he published several texts and a dissection manual for his students that portended his magnum opus. These tracts alone mark a significant advance in the field. Vesalius’ investigations culminated with his 1543 publication of De Human Corporis Fabrica Septem Libri, or Seven Books on the Fabric of the Human Body (Fig 2).7 A second edition, significantly revised and dramatically improved, appeared in 1555.8,9 Fabrica was then, and remains today, a masterpiece. Its seven books covered the skeleton, the musculature, the vasculature, the nerves, the gastrointestinal system, the heart
and lungs, and the brain, respectively. It was 663 pages, with 83 plates containing 420 illustrations, of which the “muscle men” remain the best known. Scholars have debated for centuries who actually created the figures, with the artists Titian and van Calcar as leading contenders.7 The inclusion and integration of these figures distinguished the Fabrica. Surprisingly to modern clinicians, most medieval and early modern anatomy texts lacked any illustrations, instead relying on written description to portray the human body. Berengario’s book did include a few figures, but their poor quality rendered them essentially useless. Vesalius’ images, in addition to their artistic beauty, illuminated the subject of anatomy for students and facilitated its mastery. Their seamless integration within the text set a new standard for the field. Moreover, he initiated a trend, furthered by subsequent anatomists such as Fallopio, Eustachi, and Albinus, who likewise filled their works with gorgeous and useful images, a practice continued by Netter and other modern anatomists. Fabrica, and a host of plagiarized iterations, quickly
JOURNAL OF VASCULAR SURGERY Volume 61, Number 5
spread throughout Europe, where it became the standard reference work in anatomy. Although Vesalius made numerous structural discoveries, his most important contribution came from his actual practice of dissection and his refusal to accept the teachings of Galen when his own experience dictated otherwise. He corrected Galen over and over, denying the human liver had five lobes, for example, and maintaining the mandible was a single bone. Notably, Vesalius did not reject Galen wholesale and continued to subscribe to a Galenic understanding of physiology and medicine. Crucially, though, when his experience conflicted with ancients’ writing, Vesalius trusted the former. Even this partial challenge of established medicine aroused the ire and spawned severe criticism from traditionalists, including Vesalius’ famous former professor, Sylvius. The intellectual debate that ensued racked European medicine but rather quickly concluded in favor of Vesalian practice, thus freeing the field of anatomy, and medicine more broadly, from the confines of textual dependence and launching it into an era of observation and, eventually, experimentation. VASCULAR ANATOMY Book III of Fabrica describes the vascular system. Vesalius generally hewed to a Galenic understanding of the vasculature, which held veins as the most important vessels carrying blood and nutrients from the core of the body to its periphery. However, he broke from Galen in asserting that the vena cava originated from the heart, not the liver, a conclusion he reached by measuring its diameter.10 He described the veins as being composed of three distinct layers of fiber, similar to Galen’s depiction. The arteries played a less important role than the veins in 16th century physiology, and Vesalius accordingly devoted less attention to them. “Like a vein, an artery is a membranous vessel, round and hollow like a tube, by which the vital spirit and thin, pale, warm blood are distributed through the whole body,” explained Vesalius, clearly continuing a Galenic understanding of their function.10 However, whereas Galen asserted that the blood in the arteries originated primarily from anastomoses with veins, Vesalius thought the heart supplied the blood contained in the arteries. He devotes several paragraphs to the composition of arterial walls, which he believed “much more solid and hard and composed of more tunics” than veins, although built of the same three layers of interlocking fibers.10 The necessity to contain and transmit the forceful pulsations of the heart demanded this stouter construction, Vesalius believed. He went on to identify the three coats of the arterial wall with a particularly detailed description of the intima.10 Perhaps most importantly, Vesalius was the first anatomist to dissect and describe the course of all human vessels through the body and diagram them, providing the earliest complete rendering of the vascular system (Fig 3).11 He made several specific vascular anatomy discoveries, including:
Barr 1373
d d
d
d
d
First description of the pancreaticoduodenal veins First description of the right and left gastroepiploic veins First to recognize the inferior mesenteric vein linked to the portal, not caval, system Identified the heart as the origin of the inferior vena cava (previously thought to be the liver) First to diagnose a dissecting aneurysm of the aorta, which he later confirmed by autopsy.12
Some of his anatomical discoveries had resonant physiologic implications. Most significantly, in his second edition of Fabrica in 1555, Vesalius demonstrated the impermeability of the cardiac septum.13 Galenic physiology required blood to pass from the right heart to the left heart. In proving this transit impossible, Vesalius upended the fundamental tenets of ancient medicine. Vesalius himself never took the next step to elucidate a sustainable replacement, ultimately concluding “many things present themselves here that call into doubt the ordinary conclusions of anatomists, but it would take too long to consider them, and I have decided not to alter my account piecemealdalthough at the same time I am far from satisfied.”1 However, his seminal discoveries laid the foundation for the (re)discovery of pulmonary circulation by his colleague Realdo Colombo in 1559 and the later discovery of systemic circulation by William Harvey in the 17th century.13,14 CONCLUSIONS In one of the images in Book I of Fabrica, a dissection table is emblazoned with the Latin Vivtvr Ingenio, Caetera Mortis Ervnt: genius lives on; all else is mortal. Five hundred years old in 2014, Andreas Vesalius remains revered among the medical the surgical communities. Fabrica and its spectacular illustrations endure as the most famous text in the history of medicine (although, ironically, one of the least read). In challenging Galen and privileging observation and experience over slavish textual orthodoxy, Vesalius illuminated the path toward modern medicine with a torch we endeavor to carry forward today. The author is grateful to Norman M. Rich and Luke E. Demaitre for their guidance and source suggestions. REFERENCES 1. O’Malley CD. Andreas Vesalius of Brussels: 1514e1564. Berkeley: University of California Press; 1965. 2. Nutton V. Historical introduction. In: Garrison DH, Hast MH, editors. Fabric of the human body. New York: Karger; 2004. p. lxxv-ciii. 3. Bylebyl J. The School of Padua: humanistic medicine in the sixteenth century. In: Webster C, editor. Health, medicine, and mortality in the sixteenth century. New York: Cambridge University Press; 1979. p. 335-70. 4. Park K. Secrets of women: gender, generation, and the origins of human dissection. New York: Zone Press; 2006. 5. Persaud TV. Early history of anatomy: from antiquity to the beginning of the modern era. Springfield: Thomas; 1984. 6. Cassier EA. The place of Vesalius in the culture of the Renaissance. In: Fulton JF, editor. The four hundredth anniversary celebration of the
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7.
8. 9.
10.
De Humana Corporis Fabrica of Andreas Vesalius. New Haven: Yale University Press; 1943. p. 9-20. Saunders JB, O’Malley CD. The Illustrations from the works of Andreas Vesalius of Brussels, with annotations and translations, a discussion of the plates and their background, authorship and influence, and a biographical sketch of Vesalius. New York: Dover; 1950. Cushing HW. A bio-bibliography of Andreas Vesalius. New York: Schuman’s; 1943. Horowitz M, Collins J. A census of the first edition of Andreas Vesalius’ De Humani Corporis Fabrica (1543) with a note on the recently discovered variant issue. J Hist Med Allied Sci 1984;39:198-221. Vesalius A. De Humani Corporis Fabrica Septem Libri. 1543 and 1555. In: Garrison DH, Hast MH, editors. Fabric of the human body. New York: Karger; 2014. p. 702-43.
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11. Fulton JF. The four hundredth anniversary celebration of the De Humana Corporis Fabrica of Andreas Vesalius. New Haven: Yale University Press; 1943. p. 62. 12. Biesbrouck M. Andreas Vesalius (1514e1564): Korte Schets van Zijn Leven en Werk. Available at: http://www.montanusbrugge.be/ publicaties/Vesalius%20Biesbroucktxt.pdf. Accessed August 28, 2013. 13. Bylebyl JJ. Cardiovascular physiology in the sixteenth and early seventeenth centuries. PhD dissertation. New Haven: Yale University; 1969. 14. Wilson LG. The problem of the discovery of the pulmonary circulation. J Hist Med Allied Sci 1962;XVII:229-44.
Submitted Nov 18, 2014; accepted Nov 20, 2014.
The anatomist Andreas Vesalius at 500 years old Justin Barr, PhD, Charlottesville, Va
December 31, 2014 marked 500 years since the birth of Andreas Vesalius. Praised by contemporaries and lauded by generations since as the most important anatomist in western history, he fundamentally reshaped the discipline, made numerous anatomical discoveries, and most importantly, advanced the trajectory of modern medicine by rejecting textual dependence in favor of personal observation. This article, commemorating Andreas Vesalius and his accomplishments on the 500th anniversary of his birth, will first provide a brief biography of the man. It then discusses his role as the “Father of Anatomy” and his influence in transforming the study of the human body. Finally, it highlights Vesalius’ specific contributions to vascular anatomy and physiology. A PORTRAIT OF THE MAN Andreas Vesalius (née Andries van Wesel) was born in Brussels in 1514.1,2 The son of an imperial pharmacist, he grew up in Flanders, although little is known about his early life. As an undergraduate at the University of Louvain (1529-1533), he gained the linguistic skills and humanist outlook that enabled his meteoric career. From 1533 to 1536, Vesalius studied medicine at the University of Paris, which at that time dogmatically taught the ideas of Galen. While in France, he took lessons from Jacobus Sylvius, an ardent Galenist and famous physician in his own right, who later came to oppose bitterly his student’s anatomical discoveries that denied the preeminence of the ancients. War between France and the Hapsburg Empire rendered Vesalius a persona non grata in Paris, and he completed his licentiate in medicine at Louvain in 1573, writing his thesis on the famous Arabic physician Rhazes. He transferred to the University of Paduadthe premier medical university of the eradto complete his doctorate.3 The day after graduating in 1538, he assumed the Chair of the Department of Surgery. From the School of Medicine, University of Virginia. Author conflict of interest: none. Reprint requests: Justin Barr, PhD, University of Virginia School of Medicine, PO Box 800793, Charlottesville, VA 22908 (e-mail: justbarr@gmail. com or [email protected] or [email protected]). The editors and reviewers of this article have no relevant financial relationships to disclose per the JVS policy that requires reviewers to decline review of any manuscript for which they may have a conflict of interest. J Vasc Surg 2015;61:1370-4 0741-5214 Copyright Ó 2015 by the Society for Vascular Surgery. Published by Elsevier Inc. http://dx.doi.org/10.1016/j.jvs.2014.11.080
1370
As Professor of Surgery, Vesalius educated the medical students in anatomy, a subject he preferred over clinical practice. Uniquely for the era, Vesalius insisted on the importance of actual dissection, by both teacher and pupil, when learning anatomy. His position afforded him time to study the human body and resulted in several publications, including his 1543 masterpiece Fabrica (discussed below). He dedicated and presented his book to Emperor Charles V, who subsequently appointed Vesalius to the Royal Court as medicus familiaris ordinarius, a position he retained until Charles’ abdication in 1556. Vesalius functioned largely as a military surgeon while Charles embarked on a series of campaigns through Europe. In this capacity, he, along with his contemporary, Ambroise Paré, assisted in the treatment of King Henri II’s lance wound to the head (and subsequent autopsy). Upon Charles’ abdication, Vesalius continued to serve the Hapsburgs in Spain, although he became deeply dissatisfied with his position there. In the 1560s, he went on a pilgrimage to the Holy Land. A storm waylaid his ship on the return voyage, and Vesalius died on the Mediterranean island of Zante in 1564.1,2 VESALIUS THE ANATOMIST Vesalius entered a medical world newly interested in the study of anatomy, and he totally transformed the discipline. In the beginning of the 16th century, Galen’s writings dominated the study of the human body. Cultural taboos prevented Galen from dissecting human bodies, forcing him to rely on animalsda deficiency he candidly acknowledged and one that led to numerous errors. Human dissection began in Europe as early as 1286 and had spread throughout the continent in the 1300s. Despite suggestions otherwise, the Catholic Church never officially forbade the practice.4 However, surgeons and scientists charged with performing the necropsies looked to confirm the writings of Galen, much as medical students today approach cadavers with Grant’s or Netter’s Atlas at hand, rather than as investigators seeking to uncover new truths about the structure of the human body. Moreover, most medieval physicians, surgeons, and medical students refused to sully their own hands in the corpse, instead hiring assistants of lower social stature to perform the actual dissection (Fig 1). In 1316, Mondino da Luzzi wrote the first book dedicated to anatomy since antiquity, and although based almost entirely on Galen and Avicenna, it remained the standard text for the next two centuries. In 1521, Giacomo
JOURNAL OF VASCULAR SURGERY Volume 61, Number 5
Fig 1. A medieval anatomy lesson is portrayed in this painting from Johannes de Ketham’s Fascicolo di Medicina (1491). The professor is seated high above the body and directs the dissection, although he gazes at the viewer, not the corpse. The green-frocked man is actually performing the dissection. His waist-length garment distinguishes him as belonging to a lower social class. Medical students, in long red and black robes, gather around to observe. This image is in the public domain, scanned from a facsimile copy housed in the Historical Collections and Services of the Claude B. Moore Health Sciences Library at the University of Virginia and used with their permission.
Berengario de Carpi, Professor of Anatomy at the University of Bologna, published a new text that, at 1000 pages, began to modernize the discipline. Relying at least partially on human dissection, Berengario tentatively questioned the accuracy of the ancients while making a number of new observations. Perhaps more importantly, this text, along with Guinther von Andernach’s Latin translation of Galen’s Anatomical Procedures in 1531, sparked a revival in the science of anatomy just as Vesalius began his medical studies.1,2,5 In combination with the surge of interest in anatomy, Vesalius worked in the midst of the Renaissance, when artists, philosophers, scientists, and surgeons were all expanding the boundaries of knowledge. Tellingly, the same year Vesalius wrote Fabrica, his fellow Paduan alum, Copernicus, published his monumental work expositing the heliocentric model of the universe.6 This exciting intellectual
Barr 1371
Fig 2. Frontispiece of the original 1543 edition of Fabrica. The man performing the dissection is Vesalius. Notice that the cadaver is a womandincredibly rare for the era (Vesalius only dissected two in his career)dand is disproportionately larger than all the other humans in the picture. The three weasels at the top are the Vesalius family shield. The “IO” to its left are the initials of the publisher, Johannes Oporinus, whose likeness appears as the old man peering down from the balcony. The frontispiece is replete with symbolism. The dog and the chained monkey signify Galen’s dependence on animals for anatomy. The classically dressed figures are at the same level as Vesalius, demonstrating that modern medicine was equal to that of the ancients. (The man in Greek robes on the right staring at the dog is believed to be Realdo Colombo). The skeleton in the center highlights the importance of osseous anatomy, and the nude figure clinging to the column on the left signifies the salience of surface anatomy. Perhaps most significantly, the lithograph portrays Vesalius performing the dissection himself, in stark contrast to most of his predecessors and contemporaries (depicted in Fig 1) who would sit on high and dictate the anatomy as another, lower-class individual, actually exposed the assigned structures.7 This image is in the public domain. Scans of every plate in the first edition, including this frontispiece, are freely available from the National Library of Medicine at http://www.nlm.nih.gov/exhibition/ historicalanatomies/vesalius_home.html.
climate stimulated original investigation while simultaneously fostering an environment accepting of new knowledge that contradicted previously established doctrines. Vesalius began his anatomical studies shortly after assuming his Chair at Padua. Importantly, he personally
1372 Barr
JOURNAL OF VASCULAR SURGERY May 2015
Fig 3. Plates 44 and 45 of Fabrica. Left, Plate 44 displays the veins of the body and (right) plate 45 shows the arteries. The additional detail and attention in plate 44 indicate the importance of the veins over the arteries in the 16th century. As the images display and O’Malley and Saunders describe, Vesalius did not have a perfect grasp of vascular anatomy. In plate 44, the right renal vein is mistakenly superior to the left (a relationship more common in animals), the azygos is abnormally dilated, and the veins at the base of the neck follow a nonhuman mammalian pattern. The continuity of the vena cava reflected the contemporary understanding of the role of the atria (considered part of the vessel and not of the heart). In plate 45, the aortic arch appears as a bovine variant, the lateral thoracic artery is disproportionately large for humans, and the branches of the internal and external carotid arteries are confused.7 These picayune errors aside, Vesalius’ mapping of the vasculature was a quantum leap beyond anything previously produced and served as the standard reference point for generations of physicians. The images are in the public domain. Electronic images scanned with permission from the 1555 edition housed in the Historical Collections and Services of the Claude B. Moore Health Sciences Library at the University of Virginia.
dissected cadavers, and encouraged/forced his students to do the same. Bodies typically came from the gallows or fresh graves; the local magistrate courteously timed Padua’s executions around Vesalius’ needs. That he himself worked with the cadavers represented a significant departure from previous practice and ushered in an era when merely supervising anatomy no longer sufficed. It was this hands-on engagement that enabled Vesalius to master the subject and make his portentous discoveries. While a professor, he published several texts and a dissection manual for his students that portended his magnum opus. These tracts alone mark a significant advance in the field. Vesalius’ investigations culminated with his 1543 publication of De Human Corporis Fabrica Septem Libri, or Seven Books on the Fabric of the Human Body (Fig 2).7 A second edition, significantly revised and dramatically improved, appeared in 1555.8,9 Fabrica was then, and remains today, a masterpiece. Its seven books covered the skeleton, the musculature, the vasculature, the nerves, the gastrointestinal system, the heart
and lungs, and the brain, respectively. It was 663 pages, with 83 plates containing 420 illustrations, of which the “muscle men” remain the best known. Scholars have debated for centuries who actually created the figures, with the artists Titian and van Calcar as leading contenders.7 The inclusion and integration of these figures distinguished the Fabrica. Surprisingly to modern clinicians, most medieval and early modern anatomy texts lacked any illustrations, instead relying on written description to portray the human body. Berengario’s book did include a few figures, but their poor quality rendered them essentially useless. Vesalius’ images, in addition to their artistic beauty, illuminated the subject of anatomy for students and facilitated its mastery. Their seamless integration within the text set a new standard for the field. Moreover, he initiated a trend, furthered by subsequent anatomists such as Fallopio, Eustachi, and Albinus, who likewise filled their works with gorgeous and useful images, a practice continued by Netter and other modern anatomists. Fabrica, and a host of plagiarized iterations, quickly
JOURNAL OF VASCULAR SURGERY Volume 61, Number 5
spread throughout Europe, where it became the standard reference work in anatomy. Although Vesalius made numerous structural discoveries, his most important contribution came from his actual practice of dissection and his refusal to accept the teachings of Galen when his own experience dictated otherwise. He corrected Galen over and over, denying the human liver had five lobes, for example, and maintaining the mandible was a single bone. Notably, Vesalius did not reject Galen wholesale and continued to subscribe to a Galenic understanding of physiology and medicine. Crucially, though, when his experience conflicted with ancients’ writing, Vesalius trusted the former. Even this partial challenge of established medicine aroused the ire and spawned severe criticism from traditionalists, including Vesalius’ famous former professor, Sylvius. The intellectual debate that ensued racked European medicine but rather quickly concluded in favor of Vesalian practice, thus freeing the field of anatomy, and medicine more broadly, from the confines of textual dependence and launching it into an era of observation and, eventually, experimentation. VASCULAR ANATOMY Book III of Fabrica describes the vascular system. Vesalius generally hewed to a Galenic understanding of the vasculature, which held veins as the most important vessels carrying blood and nutrients from the core of the body to its periphery. However, he broke from Galen in asserting that the vena cava originated from the heart, not the liver, a conclusion he reached by measuring its diameter.10 He described the veins as being composed of three distinct layers of fiber, similar to Galen’s depiction. The arteries played a less important role than the veins in 16th century physiology, and Vesalius accordingly devoted less attention to them. “Like a vein, an artery is a membranous vessel, round and hollow like a tube, by which the vital spirit and thin, pale, warm blood are distributed through the whole body,” explained Vesalius, clearly continuing a Galenic understanding of their function.10 However, whereas Galen asserted that the blood in the arteries originated primarily from anastomoses with veins, Vesalius thought the heart supplied the blood contained in the arteries. He devotes several paragraphs to the composition of arterial walls, which he believed “much more solid and hard and composed of more tunics” than veins, although built of the same three layers of interlocking fibers.10 The necessity to contain and transmit the forceful pulsations of the heart demanded this stouter construction, Vesalius believed. He went on to identify the three coats of the arterial wall with a particularly detailed description of the intima.10 Perhaps most importantly, Vesalius was the first anatomist to dissect and describe the course of all human vessels through the body and diagram them, providing the earliest complete rendering of the vascular system (Fig 3).11 He made several specific vascular anatomy discoveries, including:
Barr 1373
d d
d
d
d
First description of the pancreaticoduodenal veins First description of the right and left gastroepiploic veins First to recognize the inferior mesenteric vein linked to the portal, not caval, system Identified the heart as the origin of the inferior vena cava (previously thought to be the liver) First to diagnose a dissecting aneurysm of the aorta, which he later confirmed by autopsy.12
Some of his anatomical discoveries had resonant physiologic implications. Most significantly, in his second edition of Fabrica in 1555, Vesalius demonstrated the impermeability of the cardiac septum.13 Galenic physiology required blood to pass from the right heart to the left heart. In proving this transit impossible, Vesalius upended the fundamental tenets of ancient medicine. Vesalius himself never took the next step to elucidate a sustainable replacement, ultimately concluding “many things present themselves here that call into doubt the ordinary conclusions of anatomists, but it would take too long to consider them, and I have decided not to alter my account piecemealdalthough at the same time I am far from satisfied.”1 However, his seminal discoveries laid the foundation for the (re)discovery of pulmonary circulation by his colleague Realdo Colombo in 1559 and the later discovery of systemic circulation by William Harvey in the 17th century.13,14 CONCLUSIONS In one of the images in Book I of Fabrica, a dissection table is emblazoned with the Latin Vivtvr Ingenio, Caetera Mortis Ervnt: genius lives on; all else is mortal. Five hundred years old in 2014, Andreas Vesalius remains revered among the medical the surgical communities. Fabrica and its spectacular illustrations endure as the most famous text in the history of medicine (although, ironically, one of the least read). In challenging Galen and privileging observation and experience over slavish textual orthodoxy, Vesalius illuminated the path toward modern medicine with a torch we endeavor to carry forward today. The author is grateful to Norman M. Rich and Luke E. Demaitre for their guidance and source suggestions. REFERENCES 1. O’Malley CD. Andreas Vesalius of Brussels: 1514e1564. Berkeley: University of California Press; 1965. 2. Nutton V. Historical introduction. In: Garrison DH, Hast MH, editors. Fabric of the human body. New York: Karger; 2004. p. lxxv-ciii. 3. Bylebyl J. The School of Padua: humanistic medicine in the sixteenth century. In: Webster C, editor. Health, medicine, and mortality in the sixteenth century. New York: Cambridge University Press; 1979. p. 335-70. 4. Park K. Secrets of women: gender, generation, and the origins of human dissection. New York: Zone Press; 2006. 5. Persaud TV. Early history of anatomy: from antiquity to the beginning of the modern era. Springfield: Thomas; 1984. 6. Cassier EA. The place of Vesalius in the culture of the Renaissance. In: Fulton JF, editor. The four hundredth anniversary celebration of the
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De Humana Corporis Fabrica of Andreas Vesalius. New Haven: Yale University Press; 1943. p. 9-20. Saunders JB, O’Malley CD. The Illustrations from the works of Andreas Vesalius of Brussels, with annotations and translations, a discussion of the plates and their background, authorship and influence, and a biographical sketch of Vesalius. New York: Dover; 1950. Cushing HW. A bio-bibliography of Andreas Vesalius. New York: Schuman’s; 1943. Horowitz M, Collins J. A census of the first edition of Andreas Vesalius’ De Humani Corporis Fabrica (1543) with a note on the recently discovered variant issue. J Hist Med Allied Sci 1984;39:198-221. Vesalius A. De Humani Corporis Fabrica Septem Libri. 1543 and 1555. In: Garrison DH, Hast MH, editors. Fabric of the human body. New York: Karger; 2014. p. 702-43.
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11. Fulton JF. The four hundredth anniversary celebration of the De Humana Corporis Fabrica of Andreas Vesalius. New Haven: Yale University Press; 1943. p. 62. 12. Biesbrouck M. Andreas Vesalius (1514e1564): Korte Schets van Zijn Leven en Werk. Available at: http://www.montanusbrugge.be/ publicaties/Vesalius%20Biesbroucktxt.pdf. Accessed August 28, 2013. 13. Bylebyl JJ. Cardiovascular physiology in the sixteenth and early seventeenth centuries. PhD dissertation. New Haven: Yale University; 1969. 14. Wilson LG. The problem of the discovery of the pulmonary circulation. J Hist Med Allied Sci 1962;XVII:229-44.
Submitted Nov 18, 2014; accepted Nov 20, 2014.
