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Epistola docens venam axillarem dextri cubiti in dolore laterali secandam: & melancholium soccum ex venae portae ramis ...
Basel: [R. Winter], 1539. First edition of Vesalius's 'venesection letter,' one of his rarest works, embodying what may be the earliest approach to an area of medicine which may be called scientific in the modern sense. This is a fine copy, complete with the final leaf (the Cushing and Waller copies both lack it). The letter on venesection "was written for Nicolas Flourens, physician to Charles V, who had queried Vesalius regarding the notes on the azygos vein in Tabulae anatomicae sex [published by Vesalius in 1538]; Flourens wished to know what relation the vein had to the question of bloodletting in cases of pleurisy and pneumonia. Vesalius' letter advocated the new 'classical' method of letting blood near the site of the affliction, a method arousing great controversy among the medical community as it was directly opposed to the traditional 'revulsive' bleeding taught by the Arabic authorities. Although the classical method was derived from a more accurate reading of Hippocrates and Galen ... the importance of Vesalius' defense of it lies in the authority he gave to his own knowledge of the structure of the venous systeman important step in his movement away from traditional anatomical concepts" (Norman). "In this letter we perceive the first steps in the slow and gradual loosening of traditional bonds whence eventually emerged the principle that the validity of a hypothesis rests solely upon facts established by observation. Here Vesalius asks a first tentative question "whether the method of an anatomy could corroborate speculation"; a question not without moment in a day when principles based solely upon the power of the intellect were enshrined as truth ... Vesalius's fame rests upon his anatomical contributions, but he was as fully concerned with the problem of practical medicine ... The venesection letter strongly suggests that it was Vesalius's preoccupation with such clinical problems which provided the insight that enabled him to shake off the dead hand of Galen's pronouncements and make the production of the Fabrica possible" (Saunders & O'Malley, pp. 5-6). "Out of the venesection controversy came as a purely incidental finding the discovery of the venous valves ... which in the consciousness of Harvey was to provide the key to unlocking the door to the circulation" (ibid., p. 20). ABPC/RBH list only the Norman copy (in a modern binding) since 1929. "In 1538 Vesalius visited Matteo Corti, professor of medicine in Bologna, and discussed the problems of therapy by venesection. Differences of opinion between the two men seem to have been the impulse behind Vesalius' next book, Epistola docens venam axillarem dextri cubiti in dolore laterali secundam (Basel, 1539), written in support of the revived classical procedure first advocated in a posthumous publication (1525) of the Parisian physician Pierre Brissot. In this procedure blood was drawn from a site near the location of the ailment, in contrast to the Muslim and medieval practice of drawing blood from a distant part of the body. As the title of his book indicates, Vesalius sought to locate the precise site for venesection in pleurisy within the framework of the classical method. The real significance of the book lay in Vesalius' attempt to support his arguments by the location and continuity of the venous system rather than by an appeal to earlier authority. Despite his own still faulty knowledge, his method may be called scientific in relation to that of others; certainly it was nontraditional and required that his opponents resort to the same method if they wished to reply effectively. With this novel approach to the problem of venesection Vesalius posed the then striking hypothesis that anatomical dissection might be used to test speculation. Here too he declared clearly, on the basis of vivisection, that cardiac systole was synchronous with arterial expansion and for the first time mentioned his initial efforts in the preparation of the anatomical monograph that was ultimately to take shape as De humani corporis fabrica" (DSB). "Since remote antiquity, venesection had occupied a unique and important position in the minds of physicians as the sheet anchor of therapeutics. In the sixteenth century the subject had become one of violent and bitter controversy. The humanists in clearing away the rubbish of Arabian compilations and scholastic commentary had exposed how far current practice had deviated from the teachings of Hippocrates and Galen. Armed with the new learning they sought not only to defend the purified classics against the onslaughts of the Arabists, but with subtle dialectic each attempted to uphold the rightness of his textual criticism. Barren and sterile though this controversy may have been, nonetheless it was to every physician, anxious for the welfare of his patient, a subject of very real importance. Impelled by such motives and employing the familiar tools of a scholastic tradition, Vesalius enters the fray. "Hitherto, every argument rested upon acceptance of the humoral doctrine and every measure directed toward the practice of phlebotomy depended upon the opinion of Galen for its anatomical interpretation. There is, however, no part of Galen's anatomy more vulnerable and unsatisfactory than his description of the venous system. Vesalius, while fully accepting the philosophical basis of his heritage, introduces into the debate a new element, the findings of direct observation. These observations are, as he advises us, no isolated discovery, but the outcome of repeated dissections, and they enable him to challenge with growing confidence the infallibility of the Prince of Physicians. The emancipation of Vesalius begins with the venesection letter ... How significant the subject of blood-letting was in his liberation can still further be judged by the attention devoted to it again and again in both the Fabrica and in the second part of the China Root Letter directed against the attacks of his old master Sylvius ... "As Vesalius concerns himself with venesection in pleurisy, it is of particular importance to examine the opinion of Hippocrates in this respect. Pleurisy is an epidemic disease and one of the "acute affections", but venesection is to be employed only when the pain is above the diaphragm, an admonition of such importance that it is repeated a little later in the same work. This restriction in the use of venesection is somewhat puzzling. It would seem to revolve around the question of the exact meaning of the term employed by Hippocrates which has been rendered by the classical Latin authors as dolor lateralis. It has been assumed by both sixteenth-century and modern writers that the disease so described is pleurisy or some allied pulmonary disease. There can be little doubt that pleurisy is, even in classical times, usually implied by this phrase. Vesalius, however, interprets the expression, and we believe correctly, as a general one to be taken literally as "pain in the side," in which case pleurisy is but one of several diseases covered by the term, and the restriction is logical in light of theoretical considerations of the humoral pathology. In this view, Hippocrates' teaching was that one should let blood in pleurisy but not in other forms of dolor lateralis occurring below the diaphragm. The interpretation of dolor lateralis as pleurisy alone gave rise in later times to great confusion as to the rationale of its treatment ... "In the post-Galenical period, the venesection argument waxed and waned ... until we meet with the Arab practice in which bleeding was generally, if not exclusively, revulsive at a site chosen as remote as possible from the seat of the affection. The Arab practice was the standard from the mediaeval period until the sixteenth century when it was first definitely opposed as a result of the development of Greek studies and the new and accurate translation of Hippocrates and Galen ... It remained for Pierre Brissot, a physician of Paris, to enunciate and support the Hippocratic and Galenical procedure by actual practice, an epidemic of "pleurisy" in 1514 providing the opportunity. The results were, in his opinion, so brilliant that in the following year he felt called upon to make a public pronouncement, and thus began one of the most violent, acrimonious and extensive medical controversies whose repercussions extended into the seventeenth century. He condemned as Arab nonsense, the prevailing practice of slowly bleeding drop by drop from the region most distant from the site of the affection, a practice which had reached such heights of absurdity that it was thought sufficient to express a drop of blood from the big toe of the opposite side. He maintained that for bleeding to be effective, a sensible quantity of blood must be removed and since pleurisy existed in a region drained by the vena cava, it made no difference whether the right or left side was selected ... "Although Brissot obtained a few influential supporters from among his teachers at Paris, his views were received with general antagonism, but the controversy remained meanwhile a purely local affair. The explosion began some years later in Portugal whither Brissot had migrated. An epidemic of "pleurisy" at Evora in 1518 once again presented him with the opportunity of applying his principles with such success as to invite the jealousy of the royal physician, Denis, who attacked the new-fangled method in a bitter polemic. Owing to his premature death, Brissot's reply was not issued until 1525 but with its posthumous publication, the medical world promptly split into the two major factions to which Vesalius constantly refers ... "The approach of Vesalius to the controversy is unique. In general terms an adherent of the Brissot party, he stands with the champions of the purified classics but his position inflexibly rests on the secure ground of factual observation. Confident in his knowledge of the true arrangement of the azygos system, upon which the whole rationale of the place of venesection in the treatment of pleurisy rests, he is willing to go further and to promulgate on anatomical grounds his own aphorism. For the first time, the infallibility of Galen in anatomical matters is challenged. "It is unnecessary to trace any further the tortuous windings of the venesection controversy and to the extravagant excesses of blood-letting which climaxed its decay as a therapeutic method in the eighteenth century. It should be observed, however, that it was Vesalius's insistence on the significance of the azygos vein in phlebotomy which led to the discovery of the venous valves. "Despite much discussion, the entire question relating to this epochal discovery has become somewhat beclouded and confused. Yet the story is clear enough if we keep in mind the circumstances surrounding the statements of the various writers of the time and their relationship to the burning problem of phlebotomy. "The Galenical physiology and the notions based upon it naturally engendered an abnormal preoccupation with the venous system, and with the publication of the Venesection Letter and further Vesalian studies this preoccupation had become greatly intensified. One need only examine an anatomical work appearing after the middle of the sixteenth century to observe the disproportionate treatment given to the venous over the arterial system - a complete reversal from what obtains in the modern textbook - to appreciate how deeply concerned the physician was with its every detail. "The issuance of the present work had now entirely changed the complexion of the controversy. Up to the year 1539 every participant had marshaled his arguments from the pronouncements of authorities or from empirical observations on the outcome of illness, but thereafter, if he was to attack the Vesalian thesis effectively, he must adopt the new objective method of dissection. At our distance we are apt to forget that venesection was the major practical therapeutic measure evolved from the universally held humoural doctrine. Its effective exploitation depended upon knowledge of the venous system, presumed to be correct; hence, the great cogency of the Vesalian argument. From his repeated references to this earlier work in his later writings, Vesalius, no less than his contemporaries, was fully cognizant with the strength of his position. The physician, therefore, if he was to remain in the mainstream of what was to him logical and rational medicine, perforce was left by the new doctrine no option but the standard, and now ineffectual, use of polemical abuse, or he must take up the scalpel and stain his hands in the cadaver. Thus out of the venesection controversy came as a purely incidental finding the discovery of the venous valves. Their real significance could not, of course, be appreciated, because the focus of attention was on the arrangement of the veins and not on such apparently trivial details. But the question of their existence determined a Paduan tradition and so left a minor puzzle which in the consciousness of Harvey was to provide the key to unlocking the door to the circulation" (Saunders & O'Malley, pp. 5-20). "Two other matters of some importance, although unrelated to the thesis of the Venesection Letter, deserve attention. First, the observation that cardiac systole is synchronous with arterial expansion. Vesalius had given this some consideration the year before in his edition of Giunter's Institutiones anatomicae, or, as he stated in his current work. "I quietly expressed my doubts regarding that theory about which all physicians are very positive, whether the arteries and heart beat in the same way as the pulse." Now he presented his opinion more boldly: "When the heart is contracted it diffuses [vital] spirit into the aorta and blood into the pulmonary artery; this motion of the heart is systole. When, however, the ventricles of the heart are dilated, the heart receives air from the pulmonary vein and blood for the vena cava; this motion is properly the diastole of the heart. When the arteries are dilated, I believe that they are filled with vital spirit from the heart which they distribute throughout the body. However, when they are contracted I consider it obvious that the sooty vapors are expelled. Hence the motions of the heart and arteries are contradictory and contrary." "Such observation was apparently the result of vivisection, such as Vesalius may have first observed under Giunter in Paris, or similar studies which ... Vesalius asserted he had originated in Padua: "To some degree this can be proved during vivisection if one hand is placed upon the artery lying on the sacrum and the other grasps the whole of the intact heart." "As in his previous writings at Padua, so here Vesalius gives general as well as more specific promise of things to come: "I shall omit for the present the movements of the head as well as the muscles and nerves which at my modest suggestion students do well to study. Indeed, with the favor of the gods, I shall discuss this matter more fully at another time ... With regard to the rest of my studies there is little to say at present. I have now almost completed two illustrations of the nerves; in the first, the seven pairs of cranial nerves have been drawn, and in the other all the small branches of the dorsal marrow. I feel that these must be held back until I have produced illustrations of the muscles and of all the internal parts. "This year I tried a plan by which these things might be accomplished during the dissections, but it was unsuccessful with such a large group of spectators. If bodies were available here as they sometimes are elsewhere, not for long would the students lack such a useful work, especially since many distinguished men are constantly urging me to it ... besides others, Marcantonio Genua, our distinguished professor of philosophy ... has strongly urged me to the task ... If bodies become available and Joannes Stephanus, the distinguished contemporary artist, does not refuse his services, I shall certainly undertake that task." "The closing part of this statement, referring to the artist Joannes Spephanus, has led to considerable controversy in attempts to identify the artists of the Fabrica ... "The Venesection Letter concludes with the words: "Padua, from the house of the sons of the most illustrious Count Gabriel of Ortembourg, 1 January 1539." It is likely that these sons of the Count of Ortembourg, of lower Austria, with whom Vesalius seems to have been living, were students at the university, although probably not of medicine ... how long Vesalius lived with these young men is unknown, but probably it was until the end of the academic year 1538-39" (O'Malley, pp. 96-7). Cushing IV-1; NLM/Durling 4586; O'Malley, pp. 94-96; Osler 583; Waller 9898; Wellcome 6569; Norman 2136. O'Malley, Andreas Vesalius of Brussels, 1514-1564, 1964; Saunders & O'Malley, Andreas Vesalius Bruxellensis: The Bloodletting Letter of 1539: An Annotated Translation and Study of the Evolution of Vesalius's Scientific Development , 2013. 4to, pp. 66, [2, colophon], including one full-page woodcut on p. 41 after a drawing by Vesalius. 19th century red morroco, richly gilt.
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