The Evolution of Modern Medicine Part 12

The publication of the "Fabrica" shook the medical world to its foundations. Galen ruled supreme in the schools: to doubt him in the least particular roused the same kind of feeling as did doubts on the verbal inspiration of the Scriptures fifty years ago! His old teachers in Paris were up in arms: Sylvius, nostrae aetatis medicorum decus, as Vesalius calls him, wrote furious letters, and later spoke of him as a madman (vaesa.n.u.s). The younger men were with him and he had many friends, but he had aroused a roaring tide of detraction against which he protested a few years later in his work on the "China-root," which is full of details about the "Fabrica." In a fit of temper he threw his notes on Galen and other MSS. in the fire. No sadder page exists in medical writings than the one in which Vesalius tells of the burning of his books and MSS. It is here reproduced and translated.(23) His life for a couple of years is not easy to follow, but we know that in 1546 he took service with Charles V as his body physician, and the greatest anatomist of his age was lost in the wanderings of court and campaigns.

He became an active pract.i.tioner, a distinguished surgeon, much consulted by his colleagues, and there are references to many of his cases, the most important of which are to internal aneurysms, which he was one of the first to recognize. In 1555 he brought out the second edition of the "Fabrica," an even more sumptuous volume than the first.

(23) Epistle on China-root, 1546, p. 196. Vesalius may be quoted in explanation--in palliation:

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

I must show that I have since repented more than once of my impatience, and regretted that I did not take the advice of the friends who were then with me."

There is no such pathetic tragedy in the history of our profession.

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

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

There are two ways of spreading light; to be The candle or the mirror that reflects it.

I let my wick burn out--there yet remains To spread an answering surface to the flame That others kindle.

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

(*) This plate was lacking among the author's ill.u.s.trations, but the Keeper of the Ashmolean Museum remembers his repeatedly showing special interest in the sketch reproduced in John Addington Symonds's Life of Michelangelo, London, 1893, Vol. I, p. 44, and in Charles Singer's Studies in the History and Method of Science, Oxford, 1917, Vol. I, p. 97, representing Michael Angelo and a friend dissecting the body of a man, by the light of a candle fixed in the body itself.--Ed.

(24) He was the first to make and represent anatomical cross sections. See Leonardo: Quaderni d'Anatomia, Jacob Dybwad, Kristiania, 1911-1916, Vol. V.

(25) See Knox: Great Artists and Great Anatomists, London, 1862, and Mathias Duval in Les Ma.n.u.serits de Leonard de Vince: De l'Anatomie, Feuillets A, Edouard Rouveyre, Paris, 1898. For a good account of Leonardo da Vinci see Merejkovsky's novel, The Forerunner, London, 1902, also New York, Putnam.

HARVEY

LET us return to Padua about the year 1600. Vesalius, who made the school the most famous anatomical centre in Europe, was succeeded by Fallopius, one of the best-known names in anatomy, at whose death an unsuccessful attempt was made to get Vesalius back. He was succeeded in 1565 by a remarkable man, Fabricius (who usually bears the added name of Aquapendente, from the town of his birth), a worthy follower of Vesalius. In 1594, in the thirtieth year of his professoriate, he built at his own expense a new anatomical amphitheatre, which still exists in the university buildings. It is a small, high-pitched room with six standing-rows for auditors rising abruptly one above the other. The arena is not much more than large enough for the dissecting table which, by a lift, could be brought up from a preparing room below. The study of anatomy at Padua must have declined since the days of Vesalius if this tiny amphitheatre held all its students; none the less, it is probably the oldest existing anatomical lecture room, and for us it has a very special significance.

Early in his anatomical studies Fabricius had demonstrated the valves in the veins. I show you here two figures, the first, as far as I know, in which these structures are depicted. It does not concern us who first discovered them; they had doubtless been seen before, but Fabricius first recognized them as general structures in the venous system, and he called them little doors--"ostiola."

The quadrangle of the university building at Padua is surrounded by beautiful arcades, the walls and ceilings of which are everywhere covered with the stemmata, or s.h.i.+elds, of former students, many of them brilliantly painted. Standing in the arcade on the side of the "quad"

opposite the entrance, if one looks on the ceiling immediately above the capital of the second column to the left there is seen the stemma which appears as tailpiece to this chapter, put up by a young Englishman, William Harvey, who had been a student at Padua for four years. He belonged to the "Natio Anglica," of which he was Conciliarius, and took his degree in 1602. Doubtless he had repeatedly seen Fabricius demonstrate the valves of the veins, and he may indeed, as a senior student, have helped in making the very dissections from which the drawings were taken for Fabricius' work, "De Venarum Osteolis," 1603.

If one may judge from the character of the teacher's work the sort of instruction the student receives, Harvey must have had splendid training in anatomy. While he was at Padua, the great work of Fabricius, "De Visione, Voce et Auditu" (1600) was published, then the "Tractatus de Oculo Visusque Organo" (1601), and in the last year of his residence Fabricius must have been busy with his studies on the valves of the veins and with his embryology, which appeared in 1604. Late in life, Harvey told Boyle that it was the position of the valves of the veins that induced him to think of a circulation.

Harvey returned to England trained by the best anatomist of his day. In London, he became attached to the College of Physicans, and taking his degree at Cambridge, he began the practice of medicine. He was elected a fellow of the college in 1607 and physician to St. Bartholomew's Hospital in 1609. In 1615 he was appointed Lumleian lecturer to the College of Physicians, and his duties were to hold certain "public anatomies," as they were called, or lectures. We know little or nothing of what Harvey had been doing other than his routine work in the care of the patients at St. Bartholomew's. It was not until April, 1616, that his lectures began. Chance has preserved to us the notes of this first course; the MS. is now in the British Museum and was published in facsimile by the college in 1886.(26)

(26) William Harvey: Prelectiones Anatomiae Universalis, London, J. & A. Churchill, 1886.

The second day lecture, April 17, was concerned with a description of the organs of the thorax, and after a discussion on the structure and action of the heart come the lines:

W. H. constat per fabricam cordis sanguinem per pulmones in Aortam perpetuo transferri, as by two clacks of a water bellows to rayse water constat per ligaturam transitum sanguinis ab arteriis ad venas unde perpetuum sanguinis motum in circulo fieri pulsu cordis.

The ill.u.s.tration will give one an idea of the extraordinarily crabbed hand in which the notes are written, but it is worth while to see the original, for here is the first occasion upon which is laid down in clear and unequivocal words that the blood CIRCULATES. The lecture gave evidence of a skilled anatomist, well versed in the literature from Aristotle to Fabricius. In the MS. of the thorax, or, as he calls it, the "parlour" lecture, there are about a hundred references to some twenty authors. The remarkable thing is that although those lectures were repeated year by year, we have no evidence that they made any impression upon Harvey's contemporaries, so far, at least, as to excite discussions that led to publication. It was not until twelve years later, 1628, that Harvey published in Frankfurt a small quarto volume of seventy-four pages,(27) "De Motu Cordis." In comparison with the sumptuous "Fabrica" of Vesalius this is a trifling booklet; but if not its equal in bulk or typographical beauty (it is in fact very poorly printed), it is its counterpart in physiology, and did for that science what Vesalius had done for anatomy, though not in the same way. The experimental spirit was abroad in the land, and as a student at Padua, Harvey must have had many opportunities of learning the technique of vivisection; but no one before his day had attempted an elaborate piece of experimental work deliberately planned to solve a problem relating to the most important single function of the body. Herein lies the special merit of his work, from every page of which there breathes the modern spirit. To him, as to Vesalius before him, the current views of the movements of the blood were unsatisfactory, more particularly the movements of the heart and arteries, which were regarded as an active expansion by which they were filled with blood, like bellows with air.

The question of the transmission of blood through the thick septum and the transference of air and blood from the lungs to the heart were secrets which he was desirous of searching out by means of experiment.

(27) Harvey: Exercitatio Anatomica de Motu Cordis et Sanguinis in Animalibus, Francofurti, 1628.

One or two special points in the work may be referred to as ill.u.s.trating his method. He undertook first the movements of the heart, a task so truly arduous and so full of difficulties that he was almost tempted to think with Fracastorius that "the movement of the heart was only to be comprehended by G.o.d." But after many difficulties he made the following statements: first, that the heart is erected and raises itself up into an apex, and at this time strikes against the breast and the pulse is felt externally; secondly, that it is contracted every-way, but more so at the sides; and thirdly, that grasped in the hand it was felt to become harder at the time of its motion; from all of which actions Harvey drew the very natural conclusion that the activity of the heart consisted in a contraction of its fibres by which it expelled the blood from the ventricles. These were the first four fundamental facts which really opened the way for the discovery of the circulation, as it did away with the belief that the heart in its motion attracts blood into the ventricles, stating on the contrary that by its contraction it expelled the blood and only received it during its period of repose or relaxation. Then he proceeded to study the action of the arteries and showed that their period of diastole, or expansion, corresponded with the systole, or contraction, of the heart, and that the arterial pulse follows the force, frequency and rhythm of the ventricle and is, in fact, dependent upon it. Here was another new fact: that the pulsation in the arteries was nothing else than the impulse of the blood within them. Chapter IV, in which he describes the movements of the auricles and ventricles, is a model of accurate description, to which little has since been added. It is interesting to note that he mentions what is probably auricular fibrillation. He says: "After the heart had ceased pulsating an undulation or palpitation remained in the blood itself which was contained in the right auricle, this being observed so long as it was imbued with heat and spirit." He recognized too the importance of the auricles as the first to move and the last to die. The accuracy and vividness of Harvey's description of the motion of the heart have been appreciated by generations of physiologists. Having grasped this first essential fact, that the heart was an organ for the propulsion of blood, he takes up in Chapters VI and VII the question of the conveyance of the blood from the right side of the heart to the left. Galen had already insisted that some blood pa.s.sed from the right ventricle to the lungs--enough for their nutrition; but Harvey points out, with Colombo, that from the arrangement of the valves there could be no other view than that with each impulse of the heart blood pa.s.ses from the right ventricle to the lungs and so to the left side of the heart. How it pa.s.sed through the lungs was a problem: probably by a continuous transudation. In Chapters VIII and IX he deals with the amount of blood pa.s.sing through the heart from the veins to the arteries. Let me quote here what he says, as it is of cardinal import:

"But what remains to be said upon the quant.i.ty and source of the blood which thus pa.s.ses, is of a character so novel and unheard of that I not only fear injury to myself from the envy of a few, but I tremble lest I have mankind at large for my enemies, so much doth wont and custom become a second nature. Doctrine once sown strikes deeply its root, and respect for antiquity influences all men. Still the die is cast, and my trust is in my love of truth, and the candour of cultivated minds."(28) Then he goes on to say:

(28) William Harvey: Exercitatio Anatomica de Motu Cordis et Sanguinis in Animalibus, Francofurti, 1628, G. Moreton's facsimile reprint and translation, Canterbury, 1894, p. 48.

"I began to think whether there might not be A MOVEMENT, AS IT WERE, IN A CIRCLE. Now this I afterwards found to be true; and I finally saw that the blood, forced by the action of the left ventricle into the arteries, was distributed to the body at large, and its several parts, in the same manner as it is sent through the lungs, impelled by the right ventricle into the pulmonary artery, and that it then pa.s.sed through the veins and along the vena cava, and so round to the left ventricle in the manner already indicated."(29)

(29) Ibid. p. 49.

The experiments dealing with the transmission of blood in the veins are very accurate, and he uses the old experiment that Fabricius had employed to show the valves, to demonstrate that the blood in the veins flows towards the heart. For the first time a proper explanation of the action of the valves is given. Harvey had no appreciation of how the arteries and veins communicated with each other. Galen, you may remember, recognized that there were anastomoses, but Harvey preferred the idea of filtration.

The "De Motu Cordis" const.i.tutes a unique piece of work in the history of medicine. Nothing of the same type had appeared before. It is a thoroughly sensible, scientific study of a definite problem, the solution of which was arrived at through the combination of accurate observation and ingenious experiment. Much misunderstanding has arisen in connection with Harvey's discovery of the circulation of the blood.

He did not discover that the blood moved,--that was known to Aristotle and to Galen, from both of whom I have given quotations which indicate clearly that they knew of its movement,--but at the time of Harvey not a single anatomist had escaped from the domination of Galen's views.

Both Servetus and Colombo knew of the pulmonary circulation, which was described by the former in very accurate terms. Cesalpinus, a great name in anatomy and botany, for whom is claimed the discovery of the circulation, only expressed the accepted doctrines in the following oft-quoted phrase:

"We will now consider how the attraction of aliment and the process of nutrition takes place in plants; for in animals we see the aliment brought through the veins to the heart, as to a laboratory of innate heat, and, after receiving there its final perfection, distributed through the arteries to the body at large, by the agency of the spirits produced from this same aliment in the heart."(30) There is nothing in this but Galen's view, and Cesalpinus believed, as did all his contemporaries, that the blood was distributed through the body by the vena cava and its branches for the nourishment of all its parts.(*) To those who have any doubts as to Harvey's position in this matter I would recommend the reading of the "De Motu Cordis" itself, then the various pa.s.sages relating to the circulation from Aristotle to Vesalius. Many of these can be found in the admirable works of Dalton, Flourens, Richet and Curtis.(31) In my Harveian Oration for 1906(32) I have dealt specially with the reception of the new views, and have shown how long it was before the reverence for Galen allowed of their acceptance. The University of Paris opposed the circulation of the blood for more than half a century after the appearance of the "De Motu Cordis."

(30) De Plantis, Lib I, cap. 2.

(*) Cesalpinus has also a definite statement of the circlewise process.--Ed.

(31) J. C. Dalton Doctrines of the Circulation, Philadelphia, 1884; Flourens Histoire de la decouverte de la circulation du sang, 2d ed., Paris, 1857; Charles Richet Harvey, la circulation du sang, Paris, 1879; John G. Curtis Harvey's views on the use of Circulation, etc., New York, 1916.

(32) Osler An Alabama Student and Other Biographical Essays, Oxford, 1908, p. 295.

To summarize--until the seventeenth century there were believed to be two closed systems in the circulation, (1) the natural, containing venous blood, had its origin in the liver from which, as from a fountain, the blood continually ebbed and flowed for the nourishment of the body; (2) the vital, containing another blood and the spirits, ebbed and flowed from the heart, distributing heat and life to all parts. Like a bellows the lungs fanned and cooled this vital blood. Here and there we find glimmering conceptions of a communication between these systems, but practically all teachers believed that the only one of importance was through small pores in the wall separating the two sides of the heart. Observation--merely looking at and thinking about things--had done all that was possible, and further progress had to await the introduction of a new method, viz., experiment. Galen, it is true, had used this means to show that the arteries of the body contained blood and not air. The day had come when men were no longer content with accurate description and with finely spun theories and dreams. It was reserved for the immortal Harvey to put into practice the experimental method by which he demonstrated conclusively that the blood moved in a circle. The "De Motu Cordis" marks the final break of the modern spirit with the old traditions. It took long for men to realize the value of this "inventum mirabile" used so effectively by the Alexandrians--by Galen--indeed, its full value has only been appreciated within the past century. Let me quote a paragraph from my Harveian Oration.(33) "To the age of the hearer, in which men had heard and heard only, had succeeded the age of the eye in which men had seen and had been content only to see. But at last came the age of the hand--the thinking, devising, planning hand, the hand as an instrument of the mind, now re-introduced into the world in a modest little monograph from which we may date the beginning of experimental medicine."

(33) Osler: An Alabama Student, etc., pp. 329-330.

Harvey caught the experimental spirit in Italy, with brain, eye and hand as his only aids, but now an era opened in which medicine was to derive an enormous impetus from the discovery of instruments of precision. "The new period in the development of the natural sciences, which reached its height in the work of such men as Galileo, Gilbert and Kepler, is chiefly characterized by the invention of very important instruments for aiding and intensifying the perceptions of the senses, by means of which was gained a much deeper insight into the phenomena than had hitherto been possible. Such instruments as the earlier ages possessed were little more than primitive hand-made tools. Now we find a considerable number of scientifically made instruments deliberately planned for purposes of special research, and as it were, on the threshold of the period stand two of the most important, the compound microscope and the telescope. The former was invented about 1590 and the latter about 1608."(34) It was a fellow professor of the great genius Galileo who attempted to put into practice the experimental science of his friend.

With Sanctorius began the studies of temperature, respiration and the physics of the circulation. The memory of this great investigator has not been helped by the English edition of his "De Statica Medicina," not his best work, with a frontispiece showing the author in his dietetic balance. Full justice has been done to him by Dr. Weir Mitch.e.l.l in an address as president of the Congress of Physicians and Surgeons, 1891.(35) Sanctorius worked with a pulsilogue devised for him by Galileo, with which he made observations on the pulse. He is said to have been the first to put in use the clinical thermometer. His experiments on insensible perspiration mark him as one of the first modern physiologists.

(34) Dannemann: Die Naturwissenschaften in ihrer Entwickelung..., Vol. II, p. 7, Leipzig, 1911.

(35) See Transactions Congress Physicians and Surgeons, 1891, New Haven, 1892, II, 159-181.

But neither Sanctorius nor Harvey had the immediate influence upon their contemporaries which the novel and stimulating character of their work justified. Harvey's great contemporary, Bacon, although he lost his life in making a cold storage experiment, did not really appreciate the enormous importance of experimental science. He looked very coldly upon Harvey's work. It was a philosopher of another kidney, Rene Descartes, who did more than anyone else to help men to realize the value of the better way which Harvey had pointed out. That the beginning of wisdom was in doubt, not in authority, was a novel doctrine in the world, but Descartes was no armchair philosopher, and his strong advocacy and practice of experimentation had a profound influence in directing men to "la nouvelle methode." He brought the human body, the earthly machine, as he calls it, into the sphere of mechanics and physics, and he wrote the first text-book of physiology, "De l'Homme." Locke, too, became the spokesman of the new questioning spirit, and before the close of the seventeenth century, experimental research became all the mode. Richard Lower, Hooke and Hales were probably more influenced by Descartes than by Harvey, and they made notable contributions to experimental physiology in England. Borelli, author of the famous work on "The Motion of Animals" (Rome, 1680-1681), brought to the study of the action of muscles a profound knowledge of physics and mathematics and really founded the mechanical, or iatromechanical school. The literature and the language of medicine became that of physics and mechanics: wheels and pulleys, wedges, levers, screws, cords, ca.n.a.ls, cisterns, sieves and strainers, with angles, cylinders, celerity, percussion and resistance, were among the words that now came into use in medical literature.

Withington quotes a good example in a description by Pitcairne, the Scot who was professor of medicine at Leyden at the end of the seventeenth century. "Life is the circulation of the blood. Health is its free and painless circulation. Disease is an abnormal motion of the blood, either general or local. Like the English school generally, he is far more exclusively mechanical than are the Italians, and will hear nothing of ferments or acids, even in digestion. This, he declares, is a purely mechanical process due to heat and pressure, the wonderful effects of which may be seen in Papin's recently invented 'digester.' That the stomach is fully able to comminute the food may be proved by the following calculation. Borelli estimates the power of the flexors of the thumb at 3720 pounds, their average weight being 122 grains. Now, the average weight of the stomach is eight ounces, therefore it can develop a force of 117,088 pounds, and this may be further a.s.sisted by the diaphragm and abdominal muscles the power of which, estimated in the same way, equals 461,219 pounds! Well may Pitcairne add that this force is not inferior to that of any millstone."(36) Paracelsus gave an extraordinary stimulus to the study of chemistry and more than anyone else he put the old alchemy on modern lines. I have already quoted his sane remark that its chief service is in seeking remedies. But there is another side to this question. If, as seems fairly certain, the Basil Valentine whose writings were supposed to have inspired Paracelsus was a hoax and his works were made up in great part from the writings of Paracelsus, then to our medical Luther, and not to the mythical Benedictine monk, must be attributed a great revival in the search for the Philosopher's Stone, for the Elixir of Life, for a universal medicine, for the perpetuum mobile and for an aurum potabile.(37) I reproduce, almost at random, a page from the fifth and last part of the last will and testament of Basil Valentine (London, 1657), from which you may judge the chemical spirit of the time.

(36) Withington: Medical History from the Earliest Times, London, 1891, Scientific Press, p. 317.

(37) See Professor Stillman on the Basil Valentine hoax, Popular Science Monthly, New York, 1919, Lx.x.xI, 591-600.

Out of the mystic doctrines of Paracelsus arose the famous "Brothers of the Rosy Cross." "The brotherhood was possessed of the deepest knowledge and science, the trans.m.u.tation of metals, the perpetuum mobile and the universal medicine were among their secrets; they were free from sickness and suffering during their lifetime, though subject finally to death."(38)

(38) Ferguson: Bibliotheca Chemica, Vol. II, p. 290. For an account of Fludd and the English Rosicrucians see Craven's Life of Fludd, Kirkwall, 1902.

A school of a more rational kind followed directly upon the work of Paracelsus, in which the first man of any importance was Van Helmont.