November 2014 - Newsletter

3D Cadaver Anatomy Session @ NYSORA Boutique (Panasonic, Inc)

Dear NYSORA Reader,

Best regards from the NYSORA headquarters. As usual, things are brewing at NYSORA and there is much to share. In this newsletter, however, we will feature an article influenced by the celebration of the 500th birthday of Andreas Vesalius, one of the most influential figures in anatomy and medicine at large. This full-featured article gives a detailed history on the Flemish anatomist who changed the course of anatomy for the better. We will also share an interview with Dr. Kamen Vlassakov on NYSORA's Boutique Workshops. To wrap it up, we will feature our November 2014 opinion poll and a feature educational video. We look forward to seeing you and hope you've had a Happy Thanksgiving!

Sincerely,

500 Years of Vesalius

Interview with Dr Kamen Vlassakov

November 2014 NYSORA Opinion Poll

Featured Educational Video: Ultrasound-Guided Interscalene Brachial Plexus Block

Figure 1. Andreas Vesalius

Crucial to the specialty of Regional Anesthesia and Pain Medicine (RAPM), is human anatomy. In fact, it is often said that RAPM is the “practice of applied anatomy”. Therefore, it is fitting that on the occasion of his 500th birthday, we celebrate the life and work of the brilliant anatomist, Andreas Vesalius, (1514-1564) the founder of modern anatomy. Some historians argue that he influenced the thinking of his contemporaries to such an extent that our understanding of anatomy can be divided into pre and post-Vesalius eras.

From left to right: Klaas Buyse MD, Ilvana Vukovic MD, Admir Hadzic MD, Xavier Sala-Blanch MD, Emily Lynn MD, Jeff Gadsden MD and Catherine Vandeptte MD in Leuven, January 2012.

NYSORA's international team has collaborated with the Catholic University at Leuven (KUL) and the Andreas Vesalius Institute of Anatomy in Leuven to research Vesalius. Consequently, our team was privileged to gain access to some of the well-known historians of Vesalius in his home country Brabant, now Belgium. By all counts, Vesalius was an extraordinary man whose revolutionary contributions to medicine were so ahead of their time that they often involved close brushes with the law, which only served to further fuel the mystique around the man. We highlighted the lifeWe highlighted the life and work of Andreas Vesalius in November/December 2014 issue of Regional Anesthesia and Pain Medicine (Reg Anesth Pain Med. 2014 Nov-Dec;39(6):450-5. ; http://www.ncbi.nlm.nih.gov/pubmed/25340483). After a visit to one of several museum exhibits in Vesalius “home town”, Leuven Belgium, we felt compelled to share more information and the festive atmosphere in honor of one of the greatest sons of Flanders.

Mural on Vesalius Institute in Leuven, Belgium

Vesalius posters throughout Leuven, Belgium

Who was Andreas Vesalius?
Vesalius signed his publications (letters) as Andreas Vesalius Bruxellensis (meaning from Brussels). Bruxella (current Brussels in Belgium) was the capital of Brabant, then part of the Habsburg Netherlands, and belonging to the Holy Roman Empire, with Charles V as emperor. Although he was a Brabander, some have referred to him as Flemish (from Flanders, Dutch speaking northern part of Belgium). Andreas' parents actually lived in an area of Brussels where the Palace of Justice (Poelaert Plein) is now located.

The Early Life of Andreas Vesalius
Andreas Vesalius was born on New Year's Eve, 1514 in Brussels, Brabant. Vesalius was born into a wealthy family of physicians and pharmacists.¹ His father was employed as an apothecary (modern-day pharmacist) by Emperor Charles V. As with other prominent men of the Renaissance, Vesalius was born in an era of great intellectual discourse. His early education began at the Castle School of the University of Louvain where he was instructed in rhetoric, philosophy, logic, and classical languages, such as Latin, Greek and Hebrew.² Shortly thereafter, his interest turned to medicine, and he decided to go to Paris to study anatomy. According to Maurits Biesbrouck's biography (available in Dutch language only) three years later in 1536, Charles V declared war on France, and Vesalius returned to the University of Louvain where he finished his studies in medicine with the degree of licentiate (equivalent to masters degree). He presented a thesis titled “Paraphrase of nonum librum Rhaze” (Leuven, Rutgerus Rescuis, 1537), a paraphrase of the ninth book of Rhazae about the Arabic pharmacology. He was not pleased with the printing and published it again a month later in Bazel. From there on, things went very fast, Vesalius moved to the capital of the scientific Renaissance, Padua, Italy, to pursue his passion for medicine and anatomy. By December 1537, he already received his doctorate of medicine, and was nominated as a Professor. Shortly thereafter he started working there as a professor of surgery and anatomy, succeeding Paolo Colombo from Cremona.³

Anatomy before Vesalius
The dissection of corpses has taken place since recorded human history. Egyptians mummified their dead, which included cutting up their bodies and removing organs, in order to preserve the body. In their culture at the time, this was believed to be essential in order to achieve immortality in the afterlife. Although the ancient Greeks dissected human bodies, considering the dissections as an “extension of the science”,⁴ prior to the Renaissance, this was prohibited by many societies, particularly those influenced by the Roman Catholic Church. The Church controlled research and exploration for many centuries and maintained that dissecting a dead body would destroy its ability to be resurrected in the afterlife. Furthermore, in practice, the “science of the times” was not a search for truth. Instead, it was limited to supporting what currently established teachers and theories already taught.⁵ Many of the early depictions of anatomy were by the Roman physician, surgeon and philosopher in the Roman Empire Aelius Galenus, or Claudius Galenus, better known as Galen of Pergamon (born 129 AD), whose teaching came mostly from animals.

"Claude Galien". Lithograph by Pierre Roche Vigneron. (Paris: Lith de Gregoire et Deneux, ca. 1865)

His anatomical theories were standard text for medical students for over 1300 years. Like Vesalius, Galenus aspired to break the bygone boundaries of the science of the era, while his contemporaries clutched on and taught scientific principles that were already accepted.ⁱⁱⁱ Unfortunately, Galen wrote about anatomy during a time when a system of anatomical nomenclature did not exist, so it was difficult to translate and understand all of his texts. Moreover, Galen did not have a way of effectively spreading his knowledge, particularly since he wrote in Greek and everything needed to be translated, resulting in poor translations in the circulation (as opposed to Vesalius who knew his classics!). The printing press had not yet been invented, so his manuscripts had to be copied by hand, creating another obstacle and errors in reproduction.⁶ Importantly however, his work was subject to practical limitations as the dissection of human bodies was considered blasphemy and thus forbidden by the Roman Empire. Consequently, Galen was limited to work on animal dissections, usually on the Barbary monkey.

In an apparently mind-shifting experiment in 1541, Vesalius put the skeleton of a monkey and the skeleton of a human, side by side. During his examination, he found a process of the lumbar vertebrae in the monkey that was not present in the human. Galen's teachings, however, had described the human vertebrae as having that process, and Vesalius was suddenly struck with the realization that Galen had never dissected a man! He decried “I cannot wonder enough at my stupidity and trust in Galen which prevented me from seeing this before.”⁷

Anatomy during the Renaissance
The Renaissance ushered in a new era for the development of scientific medicine.⁸ The rules against use of cadavers loosened when the church deemed that the cadavers of prisoners were acceptable for scientific research.⁹ This allowed Vesalius and his contemporaries an opportunity to dissect human bodies, instead of animals, and to progressively begin the crucial transformation of the teaching in anatomy and surgery. When Vesalius entered medical school, anatomy was required but was not valued as an essential subject in educating physicians. The custom at that time was to learn about the human body by reading textbooks devoid of supporting images or illustrations; students rarely dissected corpses. Occasionally, the body of a dog, or more rarely, a human corpse, was brought into the lecture room. A common barber clumsily dissected the body while the doctor, who himself disdained the menial task of “hands-on” dissection, would read descriptions of the body from the accepted text.v Any discrepancies between the text and the demonstrations would be disregarded by the professor on the pretext that changes in the human body occurred since the manuscript had been written.¹⁰ Since there were no methods of preserving the body at the time, a complete dissection was almost impossible; the examinations were hurried and incomplete.

An illustration of a corpse hanging off gallows poll

Vesalius readily voiced his disdain for such inconsistencies in learning. He wrote in his book, Fabrica, “For, except for eight abdominal muscles shamefully mangled and in the wrong order, no other muscle or any bone, and much less an accurate series of the nerves, veins or arteries was ever demonstrated to me by anyone.” His radical views about hands-on learning not only changed the study of anatomy, but also stirred a widespread revolution. However, being labeled a “radical,” Vesalius encountered considerable resistance by the followers of Galen and by older professors who also preached that students should not study or learn from pictures of the anatomy.

Undaunted, Vesalius proceeded to perform the dissections of the human body himself and depicted his findings in pictures. He wrote, “My study of anatomy would never have succeeded had I, when working at medicine in Paris, been willing that the viscera should be merely shown to me and my fellow students ... I had to put my own hand to the business.” With this mindset, Vesalius did put his hands down to the business and began studying the anatomy, initially on the only part of the body that was freely accessible for study: the skeleton. In the 1500s, burials were often botched and incomplete, leaving bones scattered about cemeteries. Vesalius spent many hours studying these bones on the burial grounds of the Church of Innocents in Paris (now Les Buttes Chaumont). By moonlight, Vesalius and fellow students snuck onto the grounds to collect and study any scattered bones, risking being caught by the Church, or attacked by hungry dogs, who themselves had come to the cemetery in search on human remains. ⁴

During a walk outside the city walls of Louvain, Vesalius came across a skeleton chained to a wooden stake. Guessing that the skeleton was that of a criminal who had been burned at the stake, and noting that it was dried and mostly intact, Vesalius decided to steal it. He smuggled the skeleton, piece by piece over the next few days, and then reassembled it at home. 4 During his time in medical school, Vesalius became so adept at the study of anatomy that his fellow students and his teachers soon asked him to conduct the dissections instead of the barbers. ⁱⁱⁱ

The Fabrica
Through his own anatomical dissections, it soon became clear to Vesalius that Galen's anatomy was often wrong.¹² Though Vesalius was a dedicated follower of Galen and tried to believe Galen's teachings, his own observations forced him to reconsider old teaching and his own conceptions based on them. Hence, Vesalius broke away from outdated teachings and introduced new methods and principles for studying anatomy.^v Of note, Vesalius was one of the first to prepare and used anatomical charts in his early teaching of anatomy at Padua. His observations eventually led to the publication of six anatomical tables, the Tabulae Sex, in 1538, this first known hand-drawn anatomy work was widely replicated via use of the printing press^vi. The year 1543 was an important year for science. In the same year (1543) that Copernicus published De Revolutionibus, in which he claimed that Earth is not at the center of the universe¹³, Vesalius published his dissections and sketches in the most influential text: De humani corporis fabrica libri septem (The Structure of the Human Body). This Vesalius' 16th-century anatomical magnum opus De humani corporis fabrica, published in Latin in 1543 and 1555, is perhaps the most important book in the history of anatomy, revolutionizing science with its detail, insight and exquisite imagery. The work consisted of 663 pages and contained some 420 separate illustrations. The pages of the Fabrica were cut in Venice on pear wood and transported with great care to Basle, Switzerland, for printing. These wood-carved printing blocks were carried by as many as 16 mules, over the Alps, to Basle! Compare that to modern-day publishing whereby an entire book fitting on a minuscule memory stick is handed or e-mailed to a publisher! When printed, one Fabrica alone weighed 7kg, was 7 cm thick, and had a width and height of 62cm x 43cm (24.5 in x 17in). The beautiful woodcuts survived for over 400 years, until most were destroyed in an Allied air raid of Munich in 1944. An incredibly high quality of two volumes of annotated translation of the 1543 and 1545 Editions of “De Humani Corporis Fabrica” reproduction of the Fabrica has just been published in Belgium specifically for this year's 500th anniversary celebration...

Figure 2. From the Vesalius Exhibition, Leuven, Belgium

The Fabrica had more influence on the evolution of anatomy and surgery than any previously published medical book.⁶ The Fabrica, thanks to the printing press, was replicated both quickly and accurately. It was distributed throughout Europe, and was quickly adopted as the standard reference text for anatomy. The Fabrica was also cleverly dedicated to the Holy Roman Emperor, Charles V, in the hopes of garnering favor and protection from the Emperor to dodge suspicions of heresy. The publication of Fabrica also helped Vesalius to secure the position of imperial physician, in which he served until Charles V abdicated in 1556.

The Fabrica is widely held as the first great work of modern science.⁷ In the Middle Ages, physicians had difficulties performing autopsies to find causes of death as they did not know the structure of the body and could not recognize a pathology if they came across one. Consequently, the Fabrica had a vast amount of illustrations with clear anatomical detail. Vesalius combined drawings with words and labeled bones and organs, which had not been done before, FIGURE 2. He was also the first to describe the fine structure of nerves, veins, muscles, arteries and the skeleton. Despite the prevailing Galenist attitude that anatomical illustrations hindered the study of anatomy, Vesalius understood the importance of illustrations, and had Stephen van Calcar, a German-born Italian painter, one of Titian's apprentices, completed the images for the Fabrica rather then attempting to do the drawings himself.

Figure 3. The Fabrica

The drawing on the title page of the Fabrica shows Vesalius conducting a dissection on a woman, FIGURE below. Within arm's reach, there is a scalpel, a razor, a pen, an inkwell, a lighted candle and a piece of paper. The barbers, who would have been performing the dissection, are practically under the table, which suggests Vesalius' new way of teaching that preferred professors dissecting with their own hands. The Fabrica is composed of seven books: Book I describes the bones, Book II the muscles, Book III the blood vessels, Book IV the nervous system, Book V the internal organs of the abdomen, Book VI the heart and lungs, and Book VII the brain.

Andreas Vesalius and the Nervous System
Vesalius is specifically credited as being the first to describe the nerves more accurately. In that regard, the Fabrica powerfully demonstrated the power of garnering scientific knowledge through example and observation.³ For example, in the era before Vesalius, nerves were thought to be hollow and “[carried] down animal spirit from the brain to produce animal faculty for the parts of the body.”¹⁵ This animal spirit was thought to be the origin of all motion and sensation. Vesalius proved this to be false, writing, “I can assert that I never found any passage of that sort even though I dissected the optic nerves of live dogs and other large animals for this purpose, and the head of a man as yet warm and scarcely a quarter hour after his decapitation. I inspected the nerves carefully, treating them with warm water, but I was unable to discover a passage of that sort in the whole course of the nerves. Nor was it at all apparent in the juncture of the nerves, even though it ought to have been apparent there if, according to Galen's opinion, this is the reason the nerves are united.”¹⁶ Regarding the origin of nerves, he wrote, “Some consider the heart as the origin of the nerves, others the dural membrane which surrounds the brain ... From dissection of the body, it is clear that no nerve arises from the heart as it seemed to Aristotle in particular and to no few others^xv17, ”, FIGURE 4 His description of the Plexus brachialis and the Plexus ischiadicus is closely related to the modern views in these matters.

Figure 4. Illustration of the nervous system as published in Fabrica

The perils of thinking different in 1500's
While we now recognize Vesalius and his work as innovative and crucial in the development of modern medicine, many of his contemporaries actually had a different opinion of him. For one, Vesalius' fellow physicians in the Low Countries and France mocked and attacked his work. They disapproved of surgeons performing dissections as this was work for common barbers and was considered beneath the status and dignity of a physician. They also disapproved of Vesalius' criticism of Galen's teachings. The barrage of criticism, lack of acceptance of his ideas, and ruthless pressure from peers must have immensely troubled Vesalius. The mounting criticism and opposition to the acceptance of this work lead to an apparent crisis early in his career when he, on one occasion destroyed many of his unpublished manuscripts and swore he would never publish a book again.³

Eventually Vesalius managed to distance himself from his critics and saw the greater picture. His life experiences presented him with opportunities that many others did not have and those opportunities fueled his thirst for knowledge. For example, during his time as a court physician, he was often sent with the army to treat the wounded and to perform autopsies on the dead. He was also offered a temporary position as a lecturer in Italy, and for a few months, he left the imperial court to return to Italy. Over the years, Vesalius was able to perform more dissections and continued to learn through his observations of the human body. In 1555, he decided that he had to publish an updated version of the Fabrica in which the mistakes were corrected and new observations he had made were presented. In the 1555 publication, the world was introduced to valves in the veins and a much more detailed and accurate description of the human fetus. Much of Vesalius' later life however, is obscured. What is known is that upon returning from a convoluted trip to the Holy Land in 1564, the ship he was on was hit by a storm and driven ashore on the Greek island of Zakynthos, where he later died.

Piecing it all together
It is not possible to list all works related to Vesalius in this writing, as their number is vast. Therefore, the scholars of Vesalius are advised to consult the list of Vesaliana in the Hardy Cushing second edition (1962) of Vesalius' bibliography and to the most recent Vasaliana (2014) by Maurits Biesbrouck. Moreover, the work of Vesalius had forever changed the course of Anatomy as a science, as well as its applied use in surgery, arts and beyond. The Exhibit at the M Museum in Leuven is a good example of his influence throughout the centuries that ensued.

Sir Isaac Newton wrote, “If I have seen further, it is by standing upon the shoulders of giants.” Indeed, as anesthesiologists, we also stand on the shoulders of many great physician scientists like Vesalius as we continue to explore human anatomy with ultrasound and other innovative and high-resolution imaging. His relentless quest for truth and efforts to teach others helped to pioneer future breakthroughs in medicine. In this 500th anniversary celebration, we pay tribute to Andreas Vesalius for his courage to question the dogma and to push the boundaries of the law leaving us with his great discoveries in science and anatomy.

Adriaen Backer: The anatomy Lesson of dr. Frederick Ruysch, 1670, Amsterdam Museum.

Functional Anatomy of Axillary Brachial Plexus. Artist, Vali Lancea.

Even as modern medicine relies increasingly more on sophisticated imaging technologies, multi-dimensional modeling, and simulation for acquisition of skills necessary to practice medicine, anatomy and physiology to this day remain the pillars of medicine. In keeping with advances in medicine, the modern-day Vesalius institute has implemented a number of training programs for physicians in a need of acquiring highly technical operative skills required to perform complicated surgical procedures, such as joint replacement, various laparoscopic surgeries, as well as modern methods of ultrasound-guided regional anesthesia and pain medicine procedures. Therefore, even 500 years after work of Andreas Vesalius, anatomy remains an essential knowledge skill and basis for practice of medicine and surgery.

Upcoming 2nd Edition of NYSORA's Educational Posters.

Despite the widespread availability of multiple anatomical atlases, computer programs and applications, there is still not replacement for dissection and training in cadavers.

ⁱ Famous Biologists. Andreas Vesalius. Available at: http://famousbiologists.org/andreas-vesalius/ Accessed May 13, 2014.

ⁱⁱ 500 Years Vesalius. Basel, Switzerland. Karger Publishers. (Karger Publishers) Accessed May 13, 2014.

ⁱⁱⁱ Toledo-Pereyra L. De Humani Corporis Fabrica Surgical Revolution. J Invest Surg 2008; 21(5): 232-6.

^iv Tarshis J. The Father of Modern Anatomy Andreas Vesalius. New York: Dial Press, 1969.

^v Sir Foster M. Lectures on the History of Physiology during the 16, 17 and 18 Centuries. Cambridge: At the University Press, 1901.

^vi Moes R. Andreas Vesalius and the anatomy of the upper extremity. J Hand Surg 1976: 1; 23-28.

^vii Hunt D. Talks on the History of Medicine. Boston Med Surg J 1898; 139:229-234. (Hunt, 1898)

^viii Sir Cope Z. How medicine became a science. J Frank Inst 1956; 261:81-91.

^ix Nutton V. The Man. http://vesalius.northwestern.edu/chapters/FA.aa.02.html Accessed May 13, 2014.

^x Malomo AO, Idowu OE, Osuagwu FC. Lessons from History: Human Anatomy, from the Origin to the Renaissance. Int J Morphol 2006; 24:99-104.

^xi Vesalius. De humani corporis fabrica libri septem. Fol*3r. Basel: Ex officina Joannis Oporini, 1543.

^xii Vallejo-Manzur F, Perkins Y, Varon J, Baskett P. Andreas Vesalius, the concept of an artificial airway. Resuscitation 2003; 56:3-7.

^xiii Copernicus N. De Revolutionibus Orbium Coelestium. Norimbergae: apud Ioh. Petreium, 1543

^xiv Fara P. Versions of Vesalius. Endeavour 2011; 35:5-6.

^xv Vesalius. De humani corporis fabrica libri septem. p315. Basel: Ex officina Joannis Oporini, 1543.

^xvi Vesalius. De humani corporis fabrica libri septem. p324. Basel: Ex officina Joannis Oporini, 1543.

^xvii O'Malley CD. Andreas Vesalius of Brussels 1514–1564. Berkeley, CA: University of California Press, 1964.

^xviii Biesbrouck M, Vesaliana: an updated bibliography of Andreas Vesalius. http://www.andreasvesalius.be/ Accessed May 13, 2014.

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