Andreas Vesalius and the anatomy of the upper extremity

In the sixteenth century Andreas Vesalius published six anatomical tables called Tabulae Sex, which were far superior in accuracy and artistic merit to any earlier anatomical illustrations. Their publication marked the birth of modern anatomy as a science .

Robert J. Moes, M.D. Los Angeles, Calif.

Modern anatomy, and anatomy as a science, was born in 1543 with publication of Vesalius ' Fabrica , the full title of the book being De Humani Corporis Fab­rica Libri Septem, or, literally, seven books on the "fabric" or structure of the human body. This book and its author will be our chief consideration, but the full impact of Vesalius' work becomes more apparent following brief consideration of the anatomical teach­ings which preceded him. Largely these related to one man.

Galen-a given name and his only actual name, al­though he is often called Claudius-was a Greek born in 129 A. D. at Pergamum, a famous city of antiquity on the Aegean coast of Asia Minor and adjacent to Smyrna. He began the study of medicine in these cities and later studied at Alexandria. This remarkable school of antiquity, at its height in the third century B.C., per­mitted human dissection for a time. Under the later Roman domination this was discontinued, and the only human material which was available then was an ar­ticulated skeleton. Following his studies at Alexandria, Galen returned to Pergamum and, in 162 A. D., went to Rome. There he remained for much of the balance of his life, dying in or about the year 200 A.D.

Galen was a great investigator and, no doubt, a great teacher. He was handicapped by limited, if any, access to human dissection, this being forbidden by mores and also by statute in the Roman Empire. He did have frequent opportunity to observe tissues exposed by trauma and notably in .the extensive wounds of gladia­tors. However, his chief, and frequent, anatomical ma-

Received for publication April 2, 1976.

Reprint requests: Robert 1. Moes, M.D., 1260 N. Doheny Dr. , Los Angeles, Calif. 90069.

Vol. 1, No.1, pp. 23-28

terial was the monkey . A general belief is that the animal which he dissected most often was the Barbary ape, it being tail-less and presumably more like man. However, he also used the rhesus monkey, and one might consider it his possible preference inasmuch as the third digit, as in man, is the long finger in this crea­ture, whereas the fourth is the longest in the Barbary ape.

Galen was handicapped, too , by his indefinite and verbose phraseology and by the fact that there was no system of anatomical nomenclature. This made it quite impossible for any later reader to understand what Galen was describing until many centuries after his death, when dissection again was undertaken and com­parison with Galen's descriptions again was possible. Finally, Galen obviously lacked techniques of repro­duction of his text in any fashion other than by manu­script and, more important, lacked graphic representa­tion of his findings.

Nevertheless, following the decline of Rome, his teachings persisted, at first in the Eastern Roman Em­pire and later through their perpetuation by the Arab scholars. With the rise of the European universities , Galen was accepted as the chief authority in things medical and anatomical, and many translations of his works were made into Latin (the learned language of the time) from their repositories in Greek and Arabic. Actually, his teachings rarely were questioned until the publication of the Fabrica , almost l31J2 centuries after his death.

Andreas Vesalius was born in Brussels in 1514. Peo­ple of the period, if of any scholastic or other import, latinized their names, and his family name in the vulgate was Wesale or Wessels , literally weasel, this being the reason for the three weasels in the coat of

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24 Moes The Journal of

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Fig. 1. A depiction of a pre- Vesalian dissection from the title page of Berengaria Da Carpi's Isogogae Breves, Venice, 1535.

arms on the frontispiece of the Fabrica. For at least four generations his family had been physicians or quasi medical people, and Vesalius' father was an apothecary in the service of the Emperor Charles V.

The young Vesalius showed an early interest in science and spent much time perusing the many learned works in his family library . Following his preliminary education, he entered the University of Louvain when he was 14 years of age. There he undertook the clas­sical education of the period and became exceedingly proficient in Latin, although considerably less so in Greek and Hebrew , this latter and Arabic being the lan­guages of the scholars and the learned institutions which perpetuated the teachings of the ancients during the Dark Ages. It is noteworthy that Vesalius was to use all ofthese languages in the six anatomical plates, the so-called Tabulae Sex, printed in 1538 .

Following the completion of his basic education at Louvain, Vesalius left for the University of Paris, very probably in 1533, to undertake his medical education . It was there that he became outraged by the unsatis­factory teaching of ·anatomy and particularly by the fashion in which the body was dissected, or, in his own words "mangled." Dissection at Paris, when oc­casionally undertaken, was carried out in medieval and completely unsystematic fashion. It was beneath the

dignity of the professor to approach the cadaver, and he lectured from a high chair, reciting in Latin from Ga­len's book, The Use of Parts. An assistant usually pointed out the area of the body which the professor was describing from Galen's text, and the actual bun­gling dissection was carried out by lay persons, often barbers (Fig . I).

Guinther of Andernach, who translated Galen's work, Anatomical Procedures. was one of Vesalius' teachers at Paris. He spoke well of the ability of his young student, but this regard was not reciprocated in­asmuch as Vesalius later wrote, "I would not mind having as many cuts inflicted on me as I have seen him make either on man or other brute (except at the ban­queting table)."

Jacobus Sylvius was Vesalius' most important teacher at Paris. Sylvius was completely and irrevoca­bly a Galenist and, if a body being dissected displayed a situation different than that described by Galen, would teach that it was an anomaly or that it could be due to an alteration developing since Galen's time. Nevertheless, Sylvius systematized the anatomical knowledge of the period and was particularly of service in the development of standard anatomical nomencla­ture.

Vesalius did manage to do some human dissection

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Andreas Vesalius and anatomy of upper extremity 25

Fig. 2. Portrait of Vesalius from the F abrica.

while at Paris and, more important, to do it himself. Furthermore, he had access to considerable skeletal material from the gallows where executed criminals were left hanging and also from the remains removed from an old cemetery.

War broke out between France and the Empire, and Vesalius, being an enemy alien in Paris, returned to Louvain in 1536. While there he did further anatomical work, including the articulation of a skeleton and at least one dissection. During this period his only mentor was Galen, and somehow Vesalius was able to see and report the multilobed liver and other absurdities de­scribed by Galen. Even yet he had not had sufficient material and done enough himself to be certain that the ancient master was wrong.

The University of Louvain recognized Vesalius' studies at Paris and granted him the degree of Bachelor of Medicine, probably in the late spring of 1537. Thereafter he enrolled for the fall term at Padua, the university of the city state of Venice. His credits from Louvain must have been received readily and he him-

self was accepted readily at this famous school inas­much as he was granted a doctor's degree, and with honors, on Dec. 5, 1537. It is difficult to believe that he was appointed professor of surgery, which included anatomy, the following day and that he was then only 23 years of age. However, this is a bit easier to under­stand when one considers that the academic level of a surgeon of the period was far inferior to that of the physician and that Vesalius' salary was corre­spondingly lower. Following his graduation, and in that same month, he performed a dissection at Padua, with the innovation-exciting to his students-of car­rying out the entire procedure himself.

Vesalius prepared and used anatomical charts in his early teaching at Padua and it was this that led to the publication in April, 1538, of the six anatomical tables, the so called Tabulae Sex. These tables were far supe­rior in accuracy and artistic merit to any earlier anatom­ical illustrations, and their acceptance and active use is attested to by the fact that only two complete sets exist today. Nevertheless, these six tables contain errors

26 Moes

Fig. 3. First muscle plate from the second book of the Fabrica.

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based upon Vesalius' reluctance to disbelieve the teachings of Galen or even, at that point in his develop­ment, to accept the truth when he saw it before him in the body. The artist who drew the three skeletal figures of the Tabulae Sex and perhaps assisted with the other three plates, was, like Vesalius, Flemish, was named Jan Stephen Van Kalkar or Calcar and was a pupil of Titian.

From this point on, Vesalius became increasingly aware of the errors in the teachings of Galen and even more so of the inadequacy of these teachings. His op­portunities for dissection became more frequent, and he developed a systematic approach to the investigation of the cadaver and to the instruction of his students. This approach, between the winter of 1539 and the end of 1542, allowed for the development of the Fabrica and its publication in 1543.

This sumptuous folio is perhaps the greatest medical work of all time and certainly the most beautiful. It marked the beginning of anatomy as a science and, in part, the beginning of the physiological, pathological, and comparative anatomical sciences. It largely freed medicine from the shackles of Galenic anatomy, al­though the teachings of Galen would still be cham­pioned for an additional hundred years or more, and this to V esalius' great distress during his own lifetime.

The magnificent illustrations of the Fabrica are printed from woodblocks. No one knows who cut these blocks, and it is largely speculative as to who did the drawings. There is no certainty that many were done by Calcar, although it does seem probable that he was responsible for the elaborately beautiful frontispiece. Assuredly Vesalius himself did some of the drawings, very likely largely in situations where the specimen was deteriorating rapidly and no artist was readily available. Pupils of Titian, other than Calcar, may have been involved, and it is conceivable that Titian himself participated. As a matter of fact, all of the illustrations wen; attributed to Titian for a considerable period of time.

In any event, presently we are concerned only with the plates from the Fabrica which display the anatomy of the upper extremity. There are 14 such plates. These include the portrait of Vesalius and 13 of the 14 famous "muscle men."

The portrait sketch (Fig. 2) likely was done by Cal­car, certainly the actual portrayal of Vesalius' face. Presumably this was 'a good likeness, and one which pleased Vesalius, inasmuch as it was used in a total of five of his works, including the 1555 edition of the Fabrica. It remains the only portrait of Vesalius known to have been done from life. The plate has a number of

Andreas Vesalius and anatomy of upper extremity 27

inexplicable faults. The anatomist's right hand is de­picted awkwardly and seems to lack a wrist. The cada­~er, at any rate the dissected right upper extremity, is huge, a thing possibly done purposely to emphasize the importance of the dissection. Nevertheless, this woodblock print has charm and also depicts the immu­table purpose of the young Vesalius. The margin of the dissecting table shows him to be 28 years of age in 1542, the year in which the block was cut. On the table are dissecting tools and an ink pot, as if he chose to imply, "I will write about what I dissect and what I see."

The subject is standing behind the table with the par­tially dissected right upper extremity brought forward over the table and with the forearm in full supination. The skin and fascia are cleared from the member distal to the mid third of the arm. The belly of the biceps, and its insertion, are quite apparent, the lacertus fibrosus having been discarded with the fascia. The brachialis is evident on the lateral aspect of the arm. The muscle on the medial side of the arm is likely the medial head of the triceps distorted by the artist's depiction of a huge elbow and the equally tiny left hand of the ana­tomist. This left hand partially covers an oblique struc­ture, no doubt depicting the pronator teres. The bra­chioradialis is readily apparent, although its tendon is drawn poorly. The flexor carpi radialis and the flexor carpi ulnaris are turned down and left attached only at their insertions. The palmaris longus also is freed and turned down, its small muscle belly lying at the very front of the dissecting table. The continuation of the palmaris longus tendon into the palmar fascia is evident and with the fascia extended distally to the finger tips, apparently by means of the flexor tendon sheaths. The flexor digitorum superficialis, too, is freed and turned down, with a portion of its muscle in the anatomist's distorted right hand. The two slips in the distal portion of the superficialis tendon are shown clearly. The flexor profundus is well depicted, with its tendons in their proper relation to the superficialis tendons and ex­tending to the distal phalanges.

The 14 "muscle men" in the second book of the Fabrica are magnificent woodcuts, each approximately 34 cm. in height. The entire body is depicted in upright position in each plate, with seven in the anterior view, six in the posterior view, and one in profile so that the dissection may be seen from all aspects. The figures are lifelike, a thing achieved to some degree even when the destruction of the dissection almost is complete. Vesa­lius accomplished this positioning by suspending the body with a block and tackle and a nooselike rope.

The plates, particularly of the superficial muscle dis-

28 Moes

sections, were intended for the use of artists as well as medical students and continue to be used by artists today. Frequently one still sees a "muscle man" adorning illustrations or advertisements, notably those of pharmaceutical houses . It is interesting to observe that the landscape backgrounds of these figures are in sequence and depict a panorama of an area in the Euganean Hills not far from Padua. This further points out the cooperation of artists-Calcar or others of Ti­tian's school-in preparation of the drawings.

Fig . 3, the first table of the "muscle men" series, depicts all of the style, positioning, and background suggested above. The skin, fat, and fascia have been removed and the superficial musculature dissected. In the right arm we see the deltoid, the biceps, the bra­chialis, and the medial head of the triceps. The biceps tendon suggests the area from which the lacertus fi­brosus has been excised . The pronator teres is dis­played better than in the portrait. The brachioradialis and flexor carpi radial~ are shown well, and the tendon of the flexor carpi ulnaris is evident. The palmaris longus, its tendon, and the palmar fasica are depicted, and there is a suggestion of the underlying flexor super­ficialis. It may be that an attempt is made in the hypoth­ernar area to show the abductor digiti quinti and flexor digiti quinti. The thenar eminence is obscure.

The left upper extremity shows the above noted arm and forearm musculature and also the extensor carpi radialis longus and brevis . The tendons of the abductor pollicis longus and extensor pollicis brevis and longus and the extensor communis to the index are displayed. It seems possible that the extensor indicis proprius is differentiated, and it is of particular interest that Vesa­lius portrayed, and numbered, four compartments be­neath the dorsal carpal ligament.

Obviously there are errors in the plates as well as some lack of precise display of detail. Actually it is amazing that the ability of the artists, and particularly the .skill of the wood engravers, allowed for the degree

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of accuracy, as well as the beauty, of the plates of the Fabrica.

There is much more to the story of Andreas Vesa­Iius, notably his appointment as court physician to the Emperor Charles V which included service as military surgeon as well as a consultation with Ambroise Pare. The story of his pilgrimage to the Holy Land and his subsequent death on the Island of Zante while returning to resume the chair of anatomy at Padua is a sadly romantic one. He produced other books, inlucing a revised 1555 edition of the Fabrica, but Vesalius ' tremendously productive work, that which changed the science of anatomy and placed it on a scientific basis as the foundation stone of medicine, was concluded with the first appearance of that great book.

SUGGESTED READING

Andreae Vesalii Bruxellensis leones Anatomicae, Munich, 1934, Library of the University of Munich and the New York Academy of Medicine.

Choulant, Ludwig: History and bibliography of anatomic illustration (translated and annotated by Mortimer Frank) , reprint of revised edition, New York, 1962, Hafner Pub­lishing Company, Inc.

Corner, George W.: Clio medica, Anatomy, New York, 1930, Paul B. Hoeber, Inc .

Cushing , Harvey: A bio-bibliography of Andreas Vesalius, New York, 1943. Schuman's .

Melller, Cecilia A.: History of medicine, Philadelphia, 1947, The Blakiston Company.

O' Malley, C. D.: Andreas Vesalius of Brussels , Berkeley, 1964, University of California Press.

Saunders, J. B. deC M., and O' Malley, Charles D.: The illustrations from the works of Andreas Vesalius of Brus­sels, Cleveland, 1950, The World Publishing Company.

Singer, Charles: Galen on anatomical procedures, London, 1956, Oxford University Press.

Singer, Charles, and Underwood, E. Ashworth: A short his­tory of medicine, ed . 2, Oxford, 1962, Oxford University Press.

From Kidd, John: On the adaptation of external nature to the physical condition of man, London, 1852, H. G. Bohn . , p. 28.

Again quoting from Galen, The use of various parts of the body: . Man being naturally destitute of corporeal weapons, as also of any distinctive

art , has received a compensation, in the gift of that particular instrument the hand , secondly is the gift of reason; by the employment of which gifts he arms and protects his body in every mode,_ and adorns his mind with the knowledge of every art.