XXVII Edgar Mannheimer Lecture: The discovery of circulation and the origin of modern medicine during the Italian Renaissance Cardiol Young 1996; 6:109-119 © World Publishers Incorporated ISSN 1047-9511 XXVII Edgar Mannheimer Lecturef The discovery of circulation and the origin of modern medicine during the Italian Renaissance Gaetano Thiene From the University of Padua, Padova I T IS SIGNIFICANT THAT I AM DELIVERING THIS LECTUREat the University of Bologna, the oldest in the world,since this University is the "alma mater" of my own University, that of Padua. Following a dispute between the monks of Santo Stefano and the Councillors of Bologna, a group of students and professors migrated from the University of Bologna and founded the Uni- versity of Padua in 1222.1 Saint Anthony of Padua, whose eighth centenary since birth is celebrated this year, was a lecturer in Theology at the University of Bologna from 1223 to 1225, and most probably was involved in this migration. The last part of his life was spent preaching in the province of Padua, where he died on June 13, 1231. The huge number of University personnel present at his funeral gave testimony to his very close bonds of friendship with many University teachers and scholars. These scholars strongly sup- ported a petition for his canonization, which was granted in a very short time, exactly in 1232, only one year after his death, thanks to Anthony's extraordinary power to perform miracles. Among the several miracles, which allowed him to attain sanctity, I bring to your attention the particular one linked to Science and Medicine, namely the miracle of the usurer.2 A very rich, miserly merchant died in old age, and Anthony was called to bless the body. Anthony came, but denied Christian burial saying, "This man was heartless in life and his heart is now with the treasure he left." The jeweled coffer was then opened, and to the great astonishment of the onlookers, a heart was found inside. "Scientific" proof was necessary to verify the miracle, and an autopsy on the miser's body disclosed the absence of any heart within the chest (Figure 1). This miracle inspired many t Presented at the XXX Annual Meeting of the Association of European Paediatric Cardiologists, Bologna, May 17-20, 1995 Correspondence to Prof. Gaetano Thiene, Istituto di Anatomia Patologica, Via A. Gabelli, 61,35121 Padova, Italy. Tel. 39-49-827-2283; Fax. 39-49-827-2284 Accepted for publication 14 November 1995 painters. Four centuries later, in 1618, Damini painted the scene depicting Fabricius ab Acquapendente, Pro- fessor of Anatomy and Surgery at the University of Padua, as he performed the postmortem. Scholarship and Sanctity were closely linked through- out the following period of Renaissance. Many saints were scholars at the lay University of Padua before following a philanthropic or ecclesiastical calling.3 Many of them should be considered the Nobel Laureates of that time, in terms of inspiration and theological back- ground. All historians agree that Modern Science was born during the Italian Renaissance in the 15th-16th centu- ries. The Renaissance was a great revival of the liberal arts, science and religion based on humanism, namely the rediscovery of man, nature, and natural philosophy as formulated in antiquity. A new concept of erudition was advanced according to which not only mathematics and logic, but also poetry, philology and liberal arts were considered superior to metaphysics and theology. The major events determining the onset of the Re- naissance were the Fall of the Byzantine Empire in 1453, the invention of the printing press in 1452, and the discoveries of the New Worlds from 1487 to 1502. Thirst for discovery was one of the essential compo- nents of the civilization of the Renaissance fervor, and the Portuguese became the messengers and eyes and ears of Europe in the world.4 After the Fall of Constantinople in 1453, Greek culture was once again scattered all over Modern Eu- rope, and the invention of the printing press accelerated the circulation and exchange of ideas. In 1468, Cardinal Bessarione donated 482 Greek and 264 Latin codes to the Venetian Doge, thus transferring classical Greek erudition to Italian culture. At that time he wrote, "In the absence of books, the same tomb holding the body would cancel also the memory of man. "5 Erasmus of Rotterdam also came to Italy "to know Greek" in 1506. https://www.cambridge.org/core/terms. https://doi.org/10.1017/S1047951100003450 Downloaded from https://www.cambridge.org/core. Carnegie Mellon University, on 06 Apr 2021 at 01:06:14, subject to the Cambridge Core terms of use, available at https://www.cambridge.org/core/terms https://doi.org/10.1017/S1047951100003450 https://www.cambridge.org/core 110 Cardiology in the Young April 1996 Figure 1. The Usurer's Miracle by St. Anthony: the heart was found in the coffer, not in the chest. One of the fundamental achievements of the Renais- sance was the elevation of painting, sculpture and architecture to the status of liberal arts. The sculptures of incomparable Renaissance masters, such as Michel- angelo's body of Jesus Christ in the Pieta (1498-99) at Rome, display an understanding of structure that can- not be explained without accepting the sculptor's deep knowledge of the human body. In the biography of Antonio Pollaiolo, published in 1568, Giorgio Vasari reported that the artist had flayed many bodies to see the anatomy beneath.6 The sculptor Lorenzo Ghiberti, in his First Commentary of 1450, stated that "It is necessary to have seen dissection in order that the sculptor wishing to compose a "statua virile "knows how many bones are in the human body and in a like manner knows muscles and all the tendons and their connections. "b It was indeed a magic moment, during which science and art were not yet differentiated, and had not seen themselves as op- posed. It is generally believed that the dissection of cadavers was performed secretly, because it was forbidden by the authorities. This is untrue. In 1482, the University of Tubingen presented the following petition to Pope Sixtus IV: "Permission to take the bodies of legally executed criminals from the place of execution, and to dissect them according to medical rules and practice without any special license from the Holy See." The request was granted "provided the dissected bodies be given burial. "b The Venetian Moderators of Padua University wrote the following letter to the Podesta (Mayor) of Padua on December 15, 1556: "Since Anatomy is very useful to students of Medicine, and the present time is very appropri- ate, I begyour Magnificence to give some subject, sentenced to death, to the most excellent Fallopius (Professor of Anatomy) who will perform a dissection to the great expectation and satisfaction of those scholars... "7 Leonardo da Vinci (1452-1519), the greatest artist- anatomist who ever lived, conducted the most impor- tant scientific studies of the human body in the history of art. He was an exceptional individual, an artist and a scientist at one and the same time. Leonardo's anatomi- cal drawings reveal that he was a gifted observer of the human body in all its parts. He not only studied living men and women, but also dead ones, which he dissected with painstaking care in order to draw each vessel, muscle and organ with extreme precision. Although he never worked as a professional anatomist, he collabo- rated in dissecting human cadavers with Marcantonio Figure 2. Leonardo's drawing depicting the veins and blood originating from the liver (the Collection ofH.R.M. Queen Elisabeth II, Royal Library at Windsor Castle, London). https://www.cambridge.org/core/terms. https://doi.org/10.1017/S1047951100003450 Downloaded from https://www.cambridge.org/core. Carnegie Mellon University, on 06 Apr 2021 at 01:06:14, subject to the Cambridge Core terms of use, available at https://www.cambridge.org/core/terms https://doi.org/10.1017/S1047951100003450 https://www.cambridge.org/core Vol. 6, No. 2 Thiene G: Origin of Modern Medicine during the Italian Renaissance 111 della Torre, a young professor of Anatomy at the University of Pavia, from 1510 to 1511, when the plague struck that city. Leonardo had performed more than ten dissections by 1509, and more than thirty before he died. He truly combined the ability of an artist and an anatomist in a supreme manner.8 Leonardo's study of the heart dates to approximately 1511-1513, and was performed in Florence. He fol- lowed the Galenic theory of blood being generated in the liver (Figure 2), and the concept of flux and reflux through the veins: "The blood is thinner when it is more beaten, and this percussion is made by the flux and reflux of the blood generated from the two intrinsic ventricles of the heart to the extrinsic ventricles called auricles which are dilated and receive into themselves blood driven from the intrinsic ventricles and then they contract returning the blood to those extrinsic ventricles. "And again, "All veins and arteries arise from the heart, and the reason is that the biggest veins and arteries are found at their conjunction with the heart... veins arise in the gibbosity of the liver because they have their ramification in the gibbosity... " If Florence was the Center of Artistic Renaissance, where Platonism and Idealism prevailed, Padua was the Center of the Scientific Renaissance. And it was not fortuitous that architecture, the liberal art most close to science, developed under the influence of the Venetian Republic as a sort of rediscovery of the Grecian style, combined with the study of classic monuments. Andrea di Pietro della Gondola (1508-1580), known as Palladio from the Goddess Pallade, who was born in Padua and lived in Vicenza, exemplified the Humanist, and was a scholar of classical Greek art. For Palladio, the dignity of a discipline derived not only from the nobility of the subject, such as theology from God, but also from the rigor of methods and the certainty of achievements. In chapters XII-XIII of the second book of his treatise "/ quattro libri dellarchitettura"9 he describes the ideal residences of the "homo universale" (humanist) "... The town residences suit the gentleman for their magnificence and comfort as he must live there during the time needed to attendto his public andprivate affairs. But no less benefit and pleasure will he get from his country mansions, where he will spend the rest of the time looking after and improving his land and possessions, and where he will strive with his art and ingenuity to increase the wealth of the agriculture... where, given that exercise on foot and horse- riding is usually taken there, the body will more easily preserve its health and vigor, and where finally the spirit, tired by the troubles of the life of the town, will find restoration and consolation amidst the quietude of the countryside, and will pleasantly attend to the study of the Arts and the contemplation of Nature... "(Figure 3). This surely is exhortation to return to reality and "dignitas Figure 3. Villa Foscari "La Malcontenta " by Andreas Palladio, completed around 1560, mirrored in the Brenta River. Figure 4 . The upper colonnade around the courtyard Palace called "II Bo " by Andrea Moroni (1545), the finest example of Renaissance architecture in Padua. https://www.cambridge.org/core/terms. https://doi.org/10.1017/S1047951100003450 Downloaded from https://www.cambridge.org/core. Carnegie Mellon University, on 06 Apr 2021 at 01:06:14, subject to the Cambridge Core terms of use, available at https://www.cambridge.org/core/terms https://doi.org/10.1017/S1047951100003450 https://www.cambridge.org/core 112 Cardiology in the Young April 1996 Figure 5. St. Mark's Lion, symbol of the Venetian Republic. hominis" in the setting of the dialectic between culture and nature (Figure 4). By general consent, the University of Padua is cred- ited with having given rise to Modern Medicine. Butterfield in 1958 wrote: "William Harvey... was for a few years at the University of Padua, where his most important predecessors worked: Vesalius, Columbus, Fab- ricius. It is impossible to ignore that this chapter on the history of the heart is the pride of this University... Also Copernicus and Galileo were at this University during the most productive periods of their lives;... If the honor to have been the site of scientific revolution might belong to a single place, such honor should be credited to Padua, the Queen of Science. "10 Several circumstances favored the origin of Modern Science at Padua University. Its northern geographic position was strategic in favoring cultural and commer- cial exchanges with other European countries, and the use of Latin as an international language further facili- tated communication. O f utmost importance were the civil and religious freedom and tolerance, guaranteed by the Republic of Venice (Figure 5), of which Padua had been the University since 1405. The Motto of the University of Padua "Universa Universis Patavina Libertas" well underlines the importance of freedom and an open mind in international relations. The Pro- fessors enjoyed unlimited liberty in their teaching, and the University of Padua was considered "Magistra totius Europae." Incredibly enough, at that time the Univer- sity of Padua graduated as many scientists as saints. Although it was nominally a Catholic University, a profession of faith was not required from the students as was the case in other confessional Universities, like C A I E T A N V ? CWONICVJ- PAT PHIL ETTHEQL. Figure 6. Caietanus Thienaeus, Ordinary Professor of Philosophy at the Universitas Artistarum, Padua. Bologna, Pisa and Rome. This allowed the attendance and graduation of Protestant and Jewish foreign schol- ars, who formed the vast majority of the student body.''"13 With few exceptions, the English graduates of Padua were later to be found among the elite of England's medical profession. '4 The value and fame of the teachers were worldwide, and the Venetian Ambassadors scat- tered throughout the world were continuously on the lookout to single out and import the best foreign minds, offering them the position of Professor.12 "Only men of demonstrated excellence in their profession are given charge over the education of the young" was the proclamation of the Venetian Senate, thus guaranteeing the best in the Faculties of their University.13 Moreover, to prevent nepotism, neither Venetian patricians nor citizens of Padua were allowed to hold a chair of Ordinary Profes- sor, and, with a few exceptions, not even the position of Extraordinary Professor.12 From the Venetian view- point, it appears that the University had become more important than the town in which it was located or, as expressed by Bernardo Navagero, one of the Venetian overseers known as "Riformatori dello Studio di Padova," "without the University, Padua would not be Padua."14 Why this town gave rise to the so-called "scientific revolution" despite its being, among the European Universities, the one in which Aristotelian philosophy had a long-standing, and sound tradition is one of the paradoxes concerning the University of Padua.15 The biologist more than the metaphysician who was Aristotle attracted the Padovan philosophers. Aristotelism in Padua was not in any way anti-humanistic, and declared the autonomy and total separation of physics (=science) https://www.cambridge.org/core/terms. https://doi.org/10.1017/S1047951100003450 Downloaded from https://www.cambridge.org/core. Carnegie Mellon University, on 06 Apr 2021 at 01:06:14, subject to the Cambridge Core terms of use, available at https://www.cambridge.org/core/terms https://doi.org/10.1017/S1047951100003450 https://www.cambridge.org/core Vol. 6, No. 2 Thiene G: Origin of Modern Medicine during the Italian Renaissance 113 Table. University of Padua and the origin of modern medicine: milestone publications. Date 1493 1543 1559 1603 1628 1761 Publication Historia corporis humani De humani corporis fabrica De re anatomica De venarum ostiolis Exercitatio anatomica de motu cordis et sanguinis De sedibus et causis morborum per anatomen indagatis Author Alessandro Benedetti (1455-1525) Andreas Vesalius (1514-1564) Realdus Colombus (1516-1559) Hieronymus F. ab Acquapendente (1533-1619) William Harvey (1578-1657) Giovanni Battista Morgagni (1682-1771) from metaphysics (=philosophy), according to the teach- ing of Averroes. In this respect, Pietro d'Abano (1250- 1318) and Caietanus Thienaeus (1367-1465) (Figure 6) [See Editor's Note], the latter an Ordinary Professor of Philosophy in the University of Artists (=Medicine and Philosophy), were the outstanding representatives of Figure 7. Lesson of anatomy "ex cathedra " (from Fasciculus Medicinae, Venetiis, 1494). this philosophical School. Experience by observation and induction ^empiri- cism) was considered to be at the basis of scientific logic. These two prerequisites facilitated the onset of a method which proved essential for the renewal of anatomical studies by coupling objectivism with rationalism.16 The sequence of books published by the famous anatomists well depicts the history of discoveries that account for the development of modern medicine in Padua (Table). The titles of the volumes are significant for understanding the progression of knowledge, from anatomy (De Humani Corporis Fabrica, by Vesalius in 1543) to physiology (Exercitatio Anatomica de Motu Cordis et Sanguinis in Animalibus, by Harvey in 1628) to pathology (De Sedibus et Causis Morborum per Anatomen Indagatis, by Morgagni in 1761). The word anatomy appears in the title of both the anatomo- pathological and physiological textbooks, because the dissection of cadavers was essential to achieve such goals. The lesson in Anatomy was purely "ex cathedra" prior to Alessandro Benedetti (1455-1525), the first Professor to use a mobile anatomical theatre for au- topsy. While the autopsy was performed, an Extraordi- nary Professor of Medicine would read the book Anathomia by Mondino dei Luzzi, a Professor of Anatomy at the University of Bologna (1270-1326). An Ordinary Professor would concomitantly point to the viscera within the cadaver to demonstrate the truth of the statements, and nothing else could be done until such evidence was reached (Figure 7). The dissection itself was carried out by the Surgeons, who were nothing but technicians.17 With time, the doctors lost the skill of dissecting as well as the knowledge of visceral anatomy. It was with Andreas Vesalius (1514-1564) that these three positions (lector, ostensor and sector) were com- bined into a single one. The learning of anatomy was then "per ocules, non per aures" (by observation, not by hearing).18 Vesalius exemplified this spirit of inquiry into nature, to which the vast body of modern scientific knowledge owes its origin. Vesalius did not shy from handling the knife himself in order personally to con- https://www.cambridge.org/core/terms. https://doi.org/10.1017/S1047951100003450 Downloaded from https://www.cambridge.org/core. Carnegie Mellon University, on 06 Apr 2021 at 01:06:14, subject to the Cambridge Core terms of use, available at https://www.cambridge.org/core/terms https://doi.org/10.1017/S1047951100003450 https://www.cambridge.org/core 114 Cardiology in the Young April 1996 Figure 8. Portrait of Andreas Vesalius in the De Humanis Corporis Fabrica. duct the postmortem (Figure 8). Anatomy was considered the foundation of all medi- cine, and the anatomical studies of the XVIth century represented the wonderful dawning of Modern Medical Science, which culminated with the publication of De Humani Corporis Fabrica (On The Building of the Human Body) by Vesalius in 1543. This year was the turning point in the history of science during the Renaissance. With the posthumous publication of "De Revolutionibus Orbium Coelestium" by Nicolaus Copernicus (On Revolutions of Celestial Bodies), the sun replaced the earth as the center of the Universe. And it is not incidental that, with the studies of Vesalius, the heart started to replace the liver as the center of the network of vessels: heliocentrism and cardiocentrism vs geocentrism and hepatocentrism. But Vesalius was still far from the correct concept of the circulation and pulmonary function. He still be- lieved in the existence of pores in the ventricular sep- tum, and flux and reflux of the blood through the veins. In his book Tabulae Sex, published in 1540, in the drawing of heart, veins and arteries, you see that the left atrium is still considered the cavity where "Arteria venalis in sinistrum sinum aerem expulmonibus deferens " ("Pulmonary vein carries air from the lungs to the left atrium") (Figure 9). The illustrations of De Humani Corporis Fabrica are unique, and represent the perfect union between art and science.19 They are the result of a collaboration between a communicative anatomist (Andreas Vesalius) and a receptive illustrator (Stefan Van Calcar from the work- shop of Titian in Venice). In a very humanistic sense, the anatomy lesson represented the irreplaceable rite of the discovery of the values of nature and life in the most complex work of the Creation, the Human Body.20 It is impressive to recognize the likeness that exists between the Venus de Milo at the Louvre and the portrayal of a female nude by Vesalius (Figure 10). Finally, in 1543, there occurred another extraordi- nary event that changed the course of the history of Medicine. The Professor of Practical Medicine, Giovanni Battista Da Monte (1478-1551), started teaching stu- dents at the bedside, as reported in a record of a visit to the Hospital of St. Francis in Padua (April 1543, 17th visit, patient affected by syphilis).12'21 Da Monte, who was then the first Professor of Clinical Medicine in the history of Medicine, stated: unibs muffhi fnt^ommnumlwr. AHJl0pM'f«r*tH A H J 0 p f r I AJfiiftntjislr>mufciilu0mimltt. K Suttxttm viiu mtnttium cxtumt. L Adttimtrtimliimvlrmjucviu. M UmttnsftrttmtiuisAJrimiliissifir' Urn txtmtnm pcttcu. N Aifupmrti tlenas afta. O DIM/O mixmtyCmuMtummMi tix*. fmcrtm ttrfcru ftrUm iijfumiittir, i fut moxmfing/tUt cofttt prvpgmt* hutrwn l«r. P VaucwsmiextrumcorlufMtimqtrf* Q. Arttru mutts m finflnm fimam tcrim txfulmombmt dtftrni, R_ V iIM .rlmWu tx tttXto fiM fmfunuM ffffffig T UUimiJimSfnviJttTtsritim «u« V AJ utvni amum^f bilu vtfic*M* X Ki mdntuhmff tmtmum. Y htmtfMttmmpiritftiftnm. A Ai rnii,tmul(