Andreas Vesalius and the road to modern medicine

Andreas Vesalius was born Andries van Wesel on the last day of 1514, in Brussels. Now part of Belgium, at the time was part of the Netherlands. His Great-grandfather Jan, grandfather Everard, and father Anders, were all in the medical profession. After earning his degree, Jan taught at the new University of Leuven, Everard was the Royal Physician to the Emperor Maximillian and Anders followed in his father’s footsteps as Royal Apothecary, first to Maximillian, and then Charles V.

After enrolling in 1528 and studying the Arts at Leuven for four years, Andreas moved to Paris to study for a career in the Military. Here he developed an interest in anatomy, and learned the theories of Galen. Following the breakdown in relationship between France and the Roman Empire, Vesalius was forced to abandon his Paris studies in 1536 before graduating and return to Leuven where he completed his doctorate the following year. Vesalius spent some time travelling during which period he was able to study at close quarters the progression of leprosy; his findings led to increased knowledge and later successful treatment of the disease. Vesalius’ work also contributed indirectly to the increased knowledge of the progression of Bubonic plague.

In the 16th century it wasn’t unusual for trainee physicians to spend up to 14 years studying for the profession; in a time where astronomy and humors were still the basis for medical practice, it was common for students to spend up to seven years studying the stars and their alignment at various stages, knowledge of which would shape future diagnoses. Anatomy was still very much in its infancy, despite the contributions of the ancients such as Galen and influence from the great philosophers, Socrates, Plato and Aristotle. Vesalius very much took his cue from Galen, yet spent the majority of his professional career debunking the theories of anatomy that Galen had set in place, and the profession had adhered to in the interim. Surgeons and anatomists were still considered to be butchers, and the superstitions of religion played a large part in the failure of anatomy to progress as a science.

The very debate of the human soul cast a shadow on the desire to cut open corpses to obtain new information on how the body worked, indeed it is theorised that Galen proposed a lot of his ideas on dissections of dogs, apes and pure guesswork. As Galen’s theories were considered infallible, many of his ideas were still holding fast in the medical profession due simply to the notion that they were correct. Nobody thought to dispute them until Vesalius moved in with his hands on dissection of the human body, as a primary teaching tool. After his graduation he was immediately offered the chair at Padua where he took a leading role encouraging his students to adopt his hands on approach and actively urging them to check his own findings and measure them against their own. Vesalius also took a further step by opening up his autopsies to other members of the medical and nursing professions, including religious hospitals and lay-workers, with his implementation of audienced dissections.

Despite this, derogatory comments that Vesalius was nothing more than a barber surgeon followed him intermittently through his entire career. He dispelled the theories Galen had written on the workings of the heart, including publicly announcing that he could not find the holes between the left and right chambers of the heart that Galen had claimed existed to allow blood to pass through. Another theory offered that the dividing wall was porous. One esteemed physician went as far as to claim on the back of Vesalius’ contradictory findings that the human body had changed since Galen wrote up his theories.

In 1543, Vesalius published the work for which he would be best known, De Humani Corporis Fabrica, in which he cited his findings on the human heart, the vascular and circulatory systems, the skeleton, jaw, internal organs, abdominal structure and reproductive systems. He added intricate drawings of the dissected body, and brain. Nervous and Muscular systems and various miscellaneous findings. He dedicated the work to Emperor Charles V and an abridged version – written for his students – to his son Phillip II. After publication, Vesalius was offered a position as Imperial Physician at the Emperor’s Court, which led to him resigning his position at Padua. On hearing this, Duke Cosimo I de Medici offered him a position at Pisa, which he declined. Vesalius served first Charles and then, following his abdication, his son Philip.

Continuing insults of his skills by other medical professionals at the court, and rumours of his performing immoral autopsies on still-living people, that dogged his career, Vesalius eventually became the subject of an investigation into allegations he had dissected someone whose heart was still beating. No verdict was recorded, indeed the details of the investigation and its religious implications were not revealed until the following year, and still remain unsupported but Vesalius appears to have been forced to undertake a pilgrimage as penance. During his voyage, he took ill on the Greek Island of Zakynthos, where he subsequently died aged 59 in 1564. It is thought he was buried somewhere on the nearby island of Corfu.

The education of the elite medical professional had been achieved through extensive university training, with a degree being the desired result, until the eighteenth century. This training was reserved mainly for Physicians, who were also rewarded with membership to one of the professional guilds of the time. As such training required many years of costly education, it remained only within reach of the upper classes. The lower level of training was for the vast majority of other medical practitioners, surgeons and apothecaries and centred on lengthy apprenticeships with the training being provided by an established practitioner.

In the eighteenth century we saw the introduction of specialised medical schools, established in the most part by private practitioners. As more surgeons and practitioners entered these institutions, so the need for apprenticeships was removed. Some were attached to large teaching hospitals, providing instruction and lectures in return for a fee, charged by the practitioner. This provided the medical student with a chance to observe diagnosis and treatments of patients in a hospital environment.
As the end of the eighteenth century approached, and these teaching facilities gained popularity, more students were able to gain the experience and qualifications required to practice. By the end of the century, the curriculum offered by the universities was similar to that offered in these establishments, and trainee surgeons and general practitioners were learning the same areas of medicine as student physicians. Subjects included anatomy, chemistry and the theory and practice of medicine. Although attendance to a medical school would not provide the practitioner with a degree, as the physician would receive, it did serve to provide enough training to sit exams which would enable the student to gain licence to practice and membership of the appropriate guild or institute.

Traditionally there was no distinction made between the gaining of either a degree or a licence. Unlike the rest of Europe, during this period the British government played no part in the licensing laws for medical practitioners. This was the provision of the colleges and institutions that, by continuing to offer the choice of medicine or surgery licences, encouraged the divide between the two fields to continue. However as two licences were offered, many practitioners chose to take both as this increased the field in which they could practice. As a result, competition was fierce and many Physicians and practitioners felt that the situation was decidedly overcrowded. As demonstrated by an article in the Lancet, in the 1830s because of the sheer numbers of licenced practitioners, and the competition afforded by unlicensed practitioners it became impossible to earn a comfortable salary. A point supported by an anonymous article published in the Quarterly Review of 1840. One of the effects of this was the increase in licensed practitioners into the first part of the nineteenth century which did nothing to alleviate the problem.

Going into the nineteenth century we see development in Europe of licensing rules until eventually obtaining a medical degree was the only route forward in medical practice. In Britain licensing laws were reformed to bring them into line with the level of training required to obtain a degree. The General Medical Council increased the training levels of both to incorporate sixty medical licences, from nineteen licencing authorities as part of the Medical Registration Act in 1858. As a result of the increase in training that the licencing now involved, medical students increasingly chose to sit a medical degree instead. Medical schools as a result amalgamated with universities, or closed, due to lack of business.

Medical schools and the introduction of more training for medical practitioners and surgeons were an important step in the development of a standard curriculum, however, it was only when that standardisation really took shape in the mid-nineteenth century that the medical profession as we know it came about. It could be surmised that without this development, the bridge between the elite Physicians and the rest of the medical profession may not have been forged until much later on. The resulting continuance of lack of remuneration for practitioners may have continued into the twentieth century, and only really have been resolved with the introduction of the National Health Service. With the introduction of the medical curriculum, we see the emergence of specialised fields of medicine. Another benefit we have seen is better medical provision for all classes of social strata.
Many people when asked would attribute these as factors in the development of the medical profession, but I would argue that the reform began with the introduction of a standard curriculum, and that these other issues and their associated changes were results of that reform. Some felt that it was not for the benefit of the population that Medical Registration was introduced, but the need to regulate the medical profession in an effort to ensure that the professionals in the field were properly qualified and also that by reducing the numbers of doctors and consultants through this process that the money they earned was reflective of the service they offered.

Waddington, one of the major supporters of medical registration introduces an excerpt from an article in the Lancet in the early 1830s which argues that the medical profession on the whole are not wealthy, going as far as to say the majority of general practitioners “were forced to live on extremely modest incomes”. Waddington suggests that this was attributed to two factors, an overabundance of qualified practitioners, and competition from unqualified practitioners. He uses an anonymous article, attributed to Sir Benjamin Boyle in the Quarterly Review 1840 as evidence of this point. The article argues that “the competition may be…. so great as to be actually mischievous”. Waddington supports this theory somewhat with figures estimated by the Royal College of Surgeons in 1824, that the number of licences to practise medicine was 5000 which then increased by 1833 to 8125.

Waddington uses an article published in the Lancet in the 1840s which suggests that the over-abundance of medical professionals resulted in their moral and intellectual decline, and this was offered as a sound reason to regulate the numbers of members with registration. This he argues was “a relatively sophisticated statement of what was essentially an economic argument for restricting entry to the profession”. By making a moral argument to support the introduction of registration, the Lancet was theorising that the resulting restriction would have a positive effect on both the moral standards of the profession and the welfare of those they were treating. By increasing the qualification required, this would make it almost impossible for lower classes to afford the fees involved, thereby restricting entry to middle and upper class professionals. This suggests a belief by the Lancet that the moral conduct of a medical practitioner was directly connected to his social standing.

It is interesting that Waddington chooses to use the sources he does to support his argument. The Lancet is a peer–reviewed publication by medical professionals providing articles for use by the medical profession. This would suggest a method of bias, as it would seem logical for published practitioners to support their own arguments for the removal of unwanted competition. The Quarterly Review was a political publication used by many as a platform not only to support their own agenda but to decimate the character or works of other professionals. In all, this shows us that the medical profession was still at this point an area prone to moral dispute and to a degree, elitism. A situation that despite his huge contributions to modern understanding of the working of the human body, through his use of dissection, hadn’t changed much in basis, since the days of Vesalius.

Phoebe