The Men Who Made Medicine Human

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Today is the first ever installment of #ThreesomeThursday, a series where I put together three historically separate persons in one shared thematic web every first Thursday of the month.

Since I’m also running a series on the history of medicine, I decided that for this month the triumvirate will have to be involved in medicine. That’s why I chose these three.

The practice of medicine stretches way back in human history, in fact, even before history emerged. Medical doctor and essayist Lewis Thomas remarks on this long lineage saying that “doctoring has been with us since we stumbled into language and society, and will likely last forever, or for as long as we become ill and die, which is to say forever.” This means that we’ve always had doctors or people practicing some form of healing ever since our infancy as a species.

To stand out in such a field, then, is extremely difficult, because not only do you have to do something that will impact the future but that something must also stand strong against the achievements of the past. A lot of people spend their lives trying to do so but barely scratch the surface by the time they finish. That is to say, a lot fail. Today’s trio succeeded. But more than just being excellent medical personalities, these three did something to medicine that we people of today benefit from: they made medicine human.

What do I mean when I say that they made medicine human? Isn’t medicine in-itself already human because it is practiced by humans? Of course. But that’s not what I’m trying to say. When I say made human I mean to say that these three gave a human dimension to medicine: in the sense that their contributions to medicine not only improved the practice and theory of medicine, but it uncovered areas of intellect and thought that helped us better understand our place in the world, or what it is to be human.

To make myself clearer, let us start by talking about the first person in the list.

 

GALEN

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Claudius Galenus (129-216), better known to posterity as Galen, was a Greek physician from Pergamon who found fortune and fame in Rome. His foray into medicine wasn’t entirely by own admission, though. His story resembles the experience of many young professional Asians today, which is having a career carefully steered by a parent(s). When Galen was still young his father had a dream where his son would become a great physician. Not wanting it to be but a dream, he spent his waking hours helping mold young Galen into a medical prodigy. He sent Galen to study medicine at various medical institutions including Alexandria, the intellectual center for medicine at that time. At the age of 29 Galen was employed as doctor and surgeon in a school for gladiators where he steadily built a reputation as one of the finest physicians in the empire. His exploits and expertise would soon earn him an appointment in the imperial court, as he became emperor Marcus Aurelius’ chief physician. Such was the trust and confidence placed upon him by the emperor that Galen was even trusted with the care of his son, next-in-line to be emperor Commodus.

In Galen’s time, much of what comprised the medical canon was inherited from the Ancient Greeks, particularly from the Hippocratic tradition. What happened was like the passing of the Olympic torch. However, upon receiving the flame, Galen decided to take it a little bit further than he should and set ablaze many fields of inquiry along the way. Anatomy was one area that burned brightest from Galen’s arson. All those years mending and treating gladiators served him well, I suppose. Since dissection of human cadavers was considered taboo in his time, Galen made use of other animals to understand the workings of anatomy and physiology. This was a major handicap to Galen’s legacy, as this reliance on other animals led him to believe that “what is true of the anatomy of a lower animal is true also when applied to man”, says James Sands Elliot. Nonetheless, despite the errors, Galen’s contributions would last a millennium and would serve as bases of medical instruction even up to the Enlightenment.

But Galen realized that there was a unique human department in medicine that can’t be explained by using animals as analogs. Our desire for the sweet nectar that is beer cannot be explained by the want of bees to seek sustenance from flowers. Other animals have experiences that are truly and uniquely their own. The same can be said for us. Our daily experiences shape us and in effect, affect our health. What happens to you today may well be caused by something that you experienced yesterday, or the week before.

Although it wasn’t new in his time, Galen’s consistent insistence in knowing the overall condition and the medical history of his patients helped establish the art and practice of scientific consultation. In fact, Galen was so adamant to know everything related to his patients’ discomfort that he would actually conduct his investigations like a detective, centuries before Sherlock came to the scene! Take for instance this event where he diagnosed an “unknown disease”:

There was also what happened at the enquiry I held with the Stoics and Peripatetics that Boethus had assembled, and after that the case of Iustus’ wife, who was wasting away without displaying any diseased part. I discovered not only that she was in love, but also whom she loved. . . After I had diagnosed that there was no bodily illness and that the woman was troubled by some psychological disturbance, I happened to receive some information at the time of my visit which confirmed my suspicions. A man coming from the theatre remarked that he had seen Pylades dancing. Her expression and facial colour changed, and observing this and putting my hand on her wrist, I found that her pulse had suddenly become irregular in several ways, which indicates that the mind is disturbed, the same happens to those who are entering any sort of contest. The next day I told one of my followers to arrive just after I had come and seen the woman and to announce that Morphus is dancing today. When he did so, I found that her pulse was unaffected. Similarly also on the following day, when I had an announcement made about the third member of the dancing troupe, her pulse stayed steady. On the fourth evening I kept a very careful watch when it was announced that Pylades was dancing and I saw that her pulse became immediately wildly disturbed. Thus I discovered that the woman was in love with Pylades, and by careful watch on subsequent days my discovery was confirmed. (On Prognosis)

A lot would simply dismiss the experience of love as the triumph of unreason, the wild instance where thought is abandoned for ribaldry, the silent surrender from reality and the retreat to the fragile empire of fantasy. But not Galen. Everything for him was important medical information: from the irregularity of the pulse, to the change of color in the face, and the wild panic inspired just from the mention of a name. These for Galen weren’t unreason. These were physical expressions of reason that took place in the body thanks to human experience.

Which in this case, was love.

This Galenic practice failed to gain widespread attraction, though. The later rise of Christianity effected a change in morals and thought that also influenced medical practice. Illnesses and diseases that were inexplicable were relegated to a dimension which disqualified the physical and historical as causes. Anomalies in the body were thus seen as symptomatic of a spiritual crisis. The new healer, Jesus Christ, became the doctor. The enterprise of healing was again returned to the practice of divination, where divine will and whim were as much causes of disease as physical factors. The spiritual was the primary domain of concern, while the mortal body was pushed at the back. “What benefits the body is termed medicine, and what benefits the soul, instruction”, said Augustine. Religious instruction and faithful adherence to dogma were the two prime goals in life. To fall crazy in love with someone was thus to stray away from faith; and to love one another was simply to follow a set of rules designated by dogma. Doing otherwise was committing sin and welcoming worldly temptation: first-class tickets to eternal damnation.

This was the church version of malady.

Though the church had virtual influence in all facets of life, there were still pockets of faithfuls that never really accepted this mode of belief. In fact, even some in the church’s ranks thought that this was bonkers. To them, the spiritual life found full expression and joy in the physical. Nowhere was this best expressed than in the works of

 

RABELAIS

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François Rabelais (1494-1553) was a Frenchman of many things. Much more than what the word Rabelaisian, a term usually meant to designate bawdy and coarse tastes, might imply. Rabelais “mastered Latin, Greek, and Hebrew, and read widely in history, geography, and general literature”, says Jacques Barzun. He adds that Rabelais was “one of the most learned men of his time and he happened besides to be a literary genius.”

Rabelais first received religious instruction from the Fransiscan order; dissatisfied, he then transferred to the Benedictines. Both failed to fully impress him and he would later abandon the monastic life in order to study medicine where he became a specialist in transmittable diseases. It was probably due to his exposure to these two areas of study that he was able to develop his unique brand of whimsy that shocked the religious and intellectual institutions of his time.

Rabelais had something in mind: what benefits the soul wasn’t instruction, as was suggested by Augustine. The soul was nothing but an embodiment of a physical reason – an emanation from the natural, not the other way around. Access to the spiritual was thus through the physical. So to satisfy the spirit, satisfaction in the physical was necessary. Only by enjoying the exuberant extravagance in life can one reach the summit of the spirit. Drink. Eat. Laugh. Companionship. Conversations. These were all natural expressions of our physical existence as humans. No spiritual crises were necessary.

Rabelais expressed these views not in medical treatises, but in a series of vignettes about giants. Yes. Giants. As in those big burly beings that are regulars in little children’s tales. The complete saga came to be known as Gargantua and Pantagruel. The character of giants enabled Rabelais to bring up the larger than life issues that he found important but shunned by the morals of his time. For him, there was nothing bigger than the small daily events in life that we take as trivial. Take for example defecating. Grandgousier, a giant and father of another big lad named Gargantua, is amused and proud that his son had learned how to rhyme. His joy is doubled when Gargantua proudly recites the verse he had just written about the act of shitting:

Yesterday, shitting, I did know
The profit to my arse I owe;
Such was the smell that from it slunk
That I was with all bestunk.
Oh, had but then someone consented
To bring me her for whom I waited,
    Whilst shitting!
I would have closed her water-pipe
In my rough way and bunged it up,
While she had with her fingers guarded
My Jolly arsehole all bemerded
    With shitting.

In Rabelais’ world, shitting wasn’t really disgusting. It was just the body’s way of housekeeping. What goes in, must go out, albeit smellier and more pungent. This was life at its purest. Think of it as the toilet example of the first law of thermodynamics. Shitting, was simply a health issue, so why shouldn’t we talk about it? But before the body could even expel waste, it needed food. And Rabelais was one not to miss out on the joys of gluttony. Before giving birth to Gargantua, Gargamelle allowed herself the modesty to have “sixteen quarters, two bushels, and six pecks” of what was prepared on the night before her delivery. It wasn’t just baby Rabelais making her rotund, but also “the fine fecal matter to swell up inside her!” The cycle is complete. Sure, the way Rabelais went with this was with a smell of hyperbole, but in doing so, Rabelais reminds his readers that it is actually extremely normal. We know that he is exaggerating because his account of it goes against our experiences of doing it and thus we are forced to accept and confront our own physical and natural realities.

This return to the physical meant celebrating the good things in life without needing to concern oneself with the consequences that lay in the spiritual after: eat plenty and shit joyfully if you can, if it can be summarized briefly. To be Rabelaisian then is not to wallow in shit, but it is to rise above the stench and inhale the pleasures in life. It is only by taking care of the body that people can then proceed with their spiritual pursuits. The human was pushed back into the spotlight: diseases were not the decrees of the divine, but they were physiological manifestations that arose from physical causes. What we take in, what happens around us, and what we do with our bodies were the things that made us healthy. Wasn’t Christ’s message also the same? Didn’t he invite his followers to dine with him – to eat bread and drink wine? Rabelais reminds us of this message, and he especially encourages us to accept that cup:

“Down in one gulp. That’s the stuff. -Swallow it down. It’s a fine medicine.”

Now that we’re all full it’s time for us to relax and just allow the body to work its magic. And the influence of alcohol is slowly taking effect too, so now is exactly the perfect time for repose.

But the body never rests.

It works even when we’re asleep. The only time our body closes shop is when we die. And as long as we’re alive, it’s a nonstop workhorse. This we know thanks to centuries of accumulated knowledge of anatomy and physiology. Of all those who contributed to this intellectual collection, the person who really opened up what was inside of us for the world to see was

 

VESALIUS

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Unsure of what animal the clouds over the distance resembled, Hamlet hints to Polonius that it looks like a camel, to which Polonius replies, “By th’ mass, and ’tis like a camel indeed.” But Hamlet immediately takes back his initial guess, “Methinks it is like a weasel.”

Those who’ve read Shakespeare’s Hamlet knows what’s happening here. But those who haven’t are entitled to only imagine. Let me help you. Here’s a suggestion: think of a big room filled with people eager to witness what was taking place in the middle. Got it? Here are more details: in the crowd are three anachronistic audience members, there’s Aristotle, Hippocrates, and Galen. Wait, what’s going on here? Reserve your questions for later, there’s an important piece of article that you need to know: above the hall hangs a plate bearing a coat of arms. Here’s a picture of the whole event for better reference.

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“Methinks it is a weasel.”

That coat of arms does contain three weasels. Why? It was the crest of the van Wesel family, from which the young man at the center of the scene belongs to: Andreas van Wesel (1514 – 1564), Latinized as Andreas Vesalius, was only 29 when he published De humani corporis fabrica, On The Fabric of Human Body. It was the book that would end a millenium-long tradition and set medicine to a path anew.

Oh, that picture above is the frontispiece of the famed text. Isn’t it so artistic? It is. Very artistic, indeed. In fact, not only is the book regarded as a triumph in science publishing, but it is also considered as one of the finest exhibitions of anatomical art in history. But before we dissect the text and dig deeper into it, we need to familiarize ourselves with the author first and know what he was on about and why he completes this list.

Like Galen, it almost seemed like the path to medicine was already laid down for Vesalius at a young age by his parents. His father was a pharmacist and his grandfather was a physician in the court of the Holy Roman Empire. He enrolled in many universities for his medical education, but finally found his intellectual home in the University of Padua, which Vesalius himself described as “the most famous gymnasium in the world”.

He finished his studies in Padua in 1537. The day after his graduation the university employed him as professor of anatomy. Medical instruction had significantly improved by his time, and human dissections were seen with lesser disgust than was before. In the early 14th century, Mondino de Luzzi was already conducting public dissections in the University of Bologna. So it’s safe to say that people have already opened up to it a bit. But behind these advancements were hooks that slowed progress down. These clippers were the old medical traditions that Vesalius and his contemporaries inherited from Galen. And, as mentioned above, Galenic anatomy relied on using other animals as analogs to understand the human body so inaccuracies still remained. Even if de Luzzi had already uncovered the interior intricacies of the body, his findings in his 1316 Anathomia corporis humani were still largely informed by Galenic authority. The practice of dissection itself was also quite problematic. Students of medicine had to watch three people conduct the dissection: one was the lector, usually the professor who would read an anatomical text; then there was the ostensor who would point with his fingers or with an apparatus where the body part mentioned by the lector was located; and lastly there was the sector who did the dirty work of cutting and opening the body.

Take a look at the frontispiece again and see if that’s what’s happening there.

Vesalius didn’t need two extra help to teach his students. He alone conducted dissections in his classes (he also encouraged his students to do it by themselves). He thought that this system wasn’t helpful to both the students and the lecturers since the lecturer was only “haughtily repeating ideas that he didn’t learn directly from the cadaver, but that he read in other’s books.” What Vesalius exposed here was the possibility of a communication breakdown between the three: if the lecturer only repeated words in the text, how would he know if what the ostensor was pointing at was correct? How would the ostensor know if what the sector opened up was the right area instructed by the lector? Having three people not at all in sync with each other in theoretical and practical knowledge was a disaster waiting to happen.

This was Vesalius’ first major contribution to medicine. By pushing the instructor to the fore and removing the other two characters from the act, he made sure that future lecturers had the necessary skills and knowledge to conduct their own dissections.

He wasn’t about to stop with that. Knowing that much of what lecturers parroted were repetitions of mistakes from the past, he decided to embark on a writing project that would culminate in the greatest anatomical achievement of his age. Vesalius wrote a textbook that would not only serve as a basis for instruction but also provide the necessary correctives to the assertions made by Galen’s animal analogies. In-depth descriptions coupled with detailed illustrations of the body were required of that task. Vesalius was just the right man to do that. Working with the artists from the studio of the famous Titian, De fabrica contained around 250 gorgeous anatomical illustrations that are some of the most detailed and clearest illustrations of the body in history. It’s easy to identify the muscles and the bones shown in it because of how modern everything is presented.

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Screencap from the University of Cambridge youtube channel

These illustrations allowed Vesalius to easily demonstrate where Galen was wrong. For example, with the illustrations provided to him, he was able to show that the human sternum was only composed of three parts (manubrium, mesosternum, and xiphoid process) as opposed to Galen’s belief that it was seven. Comparing his findings to that of Galen’s, he concluded that “the fact is now evident that he [Galen] described (not to say imposed upon us) the fabric of the ape’s body, although the latter differs from the former in many respects.”

Vesalius knew that dissections weren’t easy, that’s why knowledge and familiarity with the tools that aided the surgeon were necessary. So he also supplied his readers with detailed accounts and illustrations of the surgical tools and apparatuses that were to be used in various stages and areas of the dissection process.

The publication of De fabrica was the turning point where medicine truly became human, since the bodies from which its study were based on were now that of humans. The instruction of medicine was also completely humanized by Vesalius in the sense that he encouraged the criticism and correction of the old master, a common and valuable practice in the humanist climate of his era. (He wasn’t the first one to criticize Galen; in the Arab world, al-Nafis and al-Razi already published their criticisms of Galen even before the publication of De fabrica).

But more importantly, Vesalius completed what Rabelais had started, which is to bridge the gap between the arts and science. His new mode of teaching anatomy prefaced what I believe to be the first instance of the medical arts, where dissection and medical instruction become almost like a theatrical performance, much like what is portrayed in the frontispiece of De fabrica. The beautiful illustrations in the book also show how art can be a useful department in transmitting scientific knowledge, and that to think that there should be a gap between the two is a failure in imagination.

Vesalius’ legacy represented a completion. The completion of a project started by Galen and revived and reinvigorated by Rabelais. The transition and completion of thought represented by these three showed that though humans can never escape death, what they do as humans remain etched in the annals of history, thus granting a select few the gift of immortality. Vesalius supplied the perfect words to describe this:

VIVITUR INGENIO, CAETERA MORTIS ERUNT

Or in English, “Genius lives on, all else is mortal.”

And as history shows, all three continue to live to this day.

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