history of medicine

The Art of Medicine

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Self-portrait from my last operation before retiring as a general surgeon nearly six years ago.

This week’s Discover Challenge at The Daily Post is all about identity so finally, after starting my blog almost three years ago and now with close to a thousand followers, this seems like just the right opportunity to introduce myself, somewhat belatedly I agree, with this self portrait, and through part of an address I gave on the Art of Medicine at a National meeting a few years ago.  If you have time to read it I hope you enjoy it and get to know me a little better than you do already.

camillia mini ii

“When I was asked to speak to you on the Art of Medicine I questioned myself as to whether or not I had the necessary credentials to address such an expert audience of educators and scholars on the subject. My only qualification, it seemed to me, was that of someone who has spent the last forty years practicing medicine and surgery, committed to helping patients to the best of my ability and dedicated to teaching students and residents, and passing on to them the knowledge, skills and art that had been passed on to me by my teachers, and always encouraging them to have the arts and humanities in their lives. Hopefully these qualifications will prove to be sufficient for my task this morning.

The art of medicine has three factors said Hippocrates… “the disease, the patient, the physician..”. a relationship that is as true today as it was over two millennia ago. But I would also like to add a fourth factor, the student. For without the student there is no future to the art. We all start out as students. We all have role models and teachers, who have guided us. That is why I have always believed that second only to my patients, my students have been the most important people in my professional life. Remember, our responsibility to be teachers is embedded in the Hippocratic oath

“…and that by precept, lecture, and every other mode of instruction, I will impart a knowledge of the Art…” reads the oath.

The art that was being imparted by Hippocrates however was founded in the belief that health was based on a balance of the elements: earth, fire, air and water; the humours: black bile, yellow bile, phlegm and blood; and the qualities of hot and cold or wet and dry. How very different is our understanding of the art today, which is based on scientific truths and the rigors of research that are so integral to the practice of medicine in the twenty first century.

There is no time in this presentation to catalogue all the scientific and clinical landmark contributions that have been made throughout the ages: Vesalius’s revelations of human anatomy in the 16th century; Harvey’s description of the circulation of the blood in the 17th; in the 18th Laenec and his stethoscope that changed, forever, the art of diagnosis; and then a few years later Moreton’s anaesthetic that set Surgery on its way; and the molecular biology and genetics of today. The message that I give to my students at every opportunity is to enrich their lives by studying the history of medicine and see unfold not only the history of our profession, but also the history of humanity.

In 1892 Sir William Osler published his Principles and Practice of Medicine, the definitive textbook of Medicine for the age. It seems only fitting to be quoting Osler at a meeting dedicated to medical education and the humanities in medicine. I opened a copy that I own, certain I would be enlightened in some way, and I was not to be disappointed, for there on the very first page was his dedication: “To the memory of my teachers.” What a great message to every practitioner opening this book, to be reminded that it is our teachers who must always be thanked for guiding us on our individual journeys. Then on the second page Osler quotes from the First Aphorism of Hippocrates ‘Experience is fallacious and judgement difficult”. It is interesting that he chose not to include the famous words that begin this aphorism: Vita brevis, ars longa, “Life is short, the Art is Long”, words that have become ever more meaningful to me as the vita becomes ever more brevis.

And this from his address to the New York Academy of Medicine in 1903:

“For the junior student in medicine and surgery it is a safe rule to have no teaching without a patient for a text, and the best teaching is that taught by the patient himself.”

How true that is. One of my patients is someone who has been an inspiration to me, and from whom I have learnt so much over the years. She is a remarkable young woman who has had Crohn’s disease from a very young age, has been through numerous surgeries and spent countless months in hospital throughout her life. I spoke with her about my presentation to you today and asked her for her perspective on the art of medicine. This is what she wrote to me:

“The Art of Medicine is maintaining the optimal balance between the scientific expertise and treatment of injury and disease, and the humanity and humility of character necessary in the promotion of a patient’s overall health and well being…Doctors today have a need for adaptability that never was present before but that being said… I believe that more and more it is up to the patient to be an active participant in their own care and treatment.”

Another of my patients writes: “The Art of Medicine is projecting a quiet but strong confidence such that the patient never doubts a positive outcome”.

From an anaesthetist colleague: “The art of medicine is the balance of science, skill, passion and compassion”.

From a surgical trainee: “The art of medicine is the ability to convince your patient that you recognize their humanity and see them as a complete human being.”

And from a first year student: “Medicine is a demonstration of love: love for humankind, curiosity for cure and a hope for the future”. Remarkable insight from a someone just beginning their studies and so very close to the words of Hippocrates, written over two thousand years ago, ”Where there is love for humanity,” he wrote “there is love for the art of medicine.”

And so, we learn from our teachers, we learn from our patients, we learn from our colleagues and we learn from our students. I’m sure you will agree with me that our responsibility as teachers is to ensure that the passion, commitment, and remarkable humanistic and artistic spirits that reside in all of our students, as they begin their journeys, just as we did ours, are nurtured, celebrated and supported at every opportunity.

My belief is that the art of medicine is about hearing as well as listening, about seeing as well as looking, about caring as well as treating and about feeling as well as touching. Perhaps, in no greater way is trust between a doctor and a patient expressed than in the laying on of hands  Touching is one of the most intimate acts that we perform as physicians. It is sacred, a defining moment, for in its action our patients know how much we care. They permit us to palpate, to percuss, to incise. My earliest memories as a medical student were watching the manner in which my teachers would touch their patients. The gentle holding of the hand, the taking of the pulse, the steady palpation to reveal the site of pain, the handshake of greeting that, with its strength, tells the patient, I am here and this moment is yours. This universal image of a student and a teacher communicating with their patient is one that I believe captures the essence of the art of medicine and one that I expressed to the students at the end of a graduation address I gave some years ago:

Listen and you will hear.
Look and you will see.
Touch and you will feel.
Treat and you will care.
Practice your art with compassion
And live your lives with passion.
Be a student always
And a teacher ever,
And your lives will be as fulfilled
And meaningful as any who have gone before
And any who are yet to come.”

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So dear followers and fellow bloggers if you made it to the end, thanks for reading all the way and learning more about this truly blest husband, father, grandfather, surgeon, teacher and artist.  As you know art is an important part of my life and has been since I was a young boy. Now that I am retired, although I do still teach and assist in surgery, I am able to spend more time in my studio and hope to continue to improve in the years to come.

Last week the subject I chose, not surprisingly, for the Weekly Photo Challenge: Future was my beautiful granddaughter who I hope one day will read today’s post and learn something about her besotted grandpa who loves her more than she could ever know.

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Celebrating the Quincentenary of Andreas Vesalius

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Andreas Vesalius, one of the greatest physicians and educators of the sixteenth century, was born in Brussels five hundred years ago today on the 31st of December 1514.  To celebrate this special day I thought I would tell the story of Vesalius and the myth of Apollo and Marsyas as it brings together the history of medicine, the history of art, mythology and some memorable images.

Vesalius studied Medicine at the University of Paris and then the University of Padua where he obtained his doctorate in 1537. He was then appointed professor of anatomy and taught there until 1543 before becoming court physician to the Emperor Charles V and subsequently his son Phillip II. He died at the early age of 50 on the Greek Island of Zakynthos.

In 1538 Vesalius published his first anatomical text, six printed sheets entitled Tabulae Anatomicae.  It was in 1543 however, at the young age of 29, that he published his greatest work, a book that Sir William Osler described as one of the most important in the history of medicine.  De Humani Corporis Fabrica Libri Septem, on the structure of the human body in seven books, is a massive work of 663 pages and marks the turning point from medieval to modern anatomy.

frontespiece

The frontispiece of the book is considered one of the great woodcuts of the 16th century. Vesalius is seen standing at the dissecting table in this stylized Teatro Anatomico in Padua teaching a crowd of students and dignitaries. This was quite unlike any professor of Anatomy from the previous two centuries who would always sit in the professorial chair reading from the works of Galen high above the dissecting table below, where a barber surgeon would be dissecting the body part under discussion.

The book contains some of the first anatomical descriptions and illustrations of human anatomy to be published, descriptions however that were considered controversial, for Vesalius had dared to challenge the authority of Galen whose anatomy, which was based on animal rather than human studies, had prevailed for nearly 1500 years.

Vesalius dedicates the Fabrica to Charles the Fifth. “Ad Dium Carolum Quintum” he writes on the opening page and then begins his Preface with the first of five large historiated initials, the letter Q for Quantumvis.

Q

In the preface Vesalius explains how essential he believes the study of human anatomy is to the future of medicine and particularly surgery, which he states had fallen into disrepute. He also expresses his concern that his work will not be recognized: “…it does not escape me” he writes,“ how little authority this effort of mine will have on account of my age, as I have not yet passed beyond my twenty-eighth year, and because of my frequent indications of Galen’s untrue beliefs.”

frontespiece 1555

In 1555 Vesalius published a second edition of the Fabrica containing a number of revisions, the first being a new frontispiece as shown above.  He also chose to begin the preface of this edition with a completely new and unique historiated initial, the letter V for Utunque; also, no doubt, V for Vesalius himself.

1552 V

As the first initial of the revised Fabrica Vesalius is clearly making a statement, although nowhere do we learn from him what that statement might be. What does this new image represent and why did he choose it?

V

It tells the story of the ancient myth of Apollo and Marsyas. The Phrygian satyr Marsyas had become skillful at playing the flute and challenged the god Apollo to a musical duel. This was judged by the muses who declared Apollo, with the divine sound of his stringed lyre, the winner. As punishment for his impudence Apollo flayed Marsyas alive.

This story appears to have captured the imagination of poets, emperors, popes, artists and now anatomists. It was first recorded in the fifth century BC by Herodotus, was re-told in Ovid’s Metamorphoses, and referred to in Dante’s Divine Comedy.

prologue

This 15th century woodcut above provides us with a prologue to the myth. In the distance the goddess Athena is seen playing her flute to the gods on Olympus, who were said to have laughed at her. When later she sees her reflection in a stream with her cheeks puffed out as she plays, she curses the instrument and discards it. Marsyas finds it and teaches himself to play. Feeling invincible he challenges Apollo to the musical duel in which the muses judge him to be the loser. Apollo flays him alive and his skin is seen hanging in the distant temple.

In antiquity statues of Marsyas were described on the Acropolis in Athens and later in the Roman Forum. The relief below is in the Athens Museum and shows Apollo with his lyre, the executioner his knife ready, and Marsyas playing the double pipe. On the right is a small marble from the Museum on the Greek Island of Kos, birthplace of Hippocrates, showing Marsyas hanging by his arms awaiting his fate.

Athens A&M      Kos M

This beautiful carnelian gem was made for the Emperor Augustus and is now in the Museo Nazionale in Naples. In the 15th century it came into the possession of Lorenzo de Medici who made an impression from the gem that reveals its exquisite detail.  Marsyas, his arms bound is seated on a panther skin, the symbol of Dionysus, his pipes hanging from the tree behind him and the triumphant Apollo standing impassively with lyre in hand.

.     gem          Medici

It has been suggested that the Belvedere Torso in the Vatican, so much admired by Michelangelo, may well be a seated Marsyas. The figure is in the same pose as seen in the Augustan gem, and is similarly seated on a panther skin.

Belvedere torso

Many artists have been inspired to reproduce the myth. In the ceiling of the Stanza della Segnatura, in the Vatican, Raphael has placed it between representations of poetry and theology. The executioner, knife poised, awaits Apollo’s command to begin his work.

Raffael Marsyas            ceiling

In this pen and ink wash from the Louvre in Paris by Giulio Romano in 1527 Marsyas has been suspended and his punishment is already underway.

Romano

Romano’s image was perhaps the source of the last painting of Titian, the greatest Venetian artist of the sixteenth century. This painting of the Flaying of Marsyas was found in his studio after his death in 1576 and is perhaps the most moving representation of the myth, expressing life and death, harmony and discord, sacrifice and salvation.

Titian

Which brings us back to Vesalius and the Fabrica. What were his intentions in representing the myth? Did he see himself as Apollo, or Marsyas, or perhaps both? He certainly had challenged fifteen hundred years of established Galenic anatomy, which was being taught in the universities of Europe. He had been publicly flayed in print by his old teacher Sylvius for doing so and had been described by him as a “mad deserter, wholly arrogant and wholly ignorant”.

V

Yet Vesalius knew that his work was about absolute truth. The harmony of the universe represented by the music of Apollo’s lyre is ever linked to the harmony and spirit residing in the human body. The beauty and strength of the flayed figures in the Fabrica express this belief. The skin may be gone but the body stands strong and tall; Marsyas lives.

muscle figure

On this quincentenary of his birth it is Andreas Vesalius, the Apollo of all the teachers of anatomy, whom we remember today.  His dedication to the teaching and writing of human anatomy became the foundation of modern medicine and surgery. We have much to thank him for.

Key references: O’Malley C. Andreas Vesalius of Brussels 1514-1564. University of California Press, Berkeley and Los Angeles, 1964; Lambert S.W. The Initial Letters of the Anatomical Treatise, De Humani Corporis Fabrica, of Vesalius, in Three Vesalian Essays to Accompany the Icones Anatomicae of 1934. The Macmillan Company, New York 1952; Wyss E. The Myth of Apollo and Marsyas in the Art of the Italian Renaissance. University of Delaware Press, Newark; Associated University Presses, London 1996