ANDREAS VESALIUS BRUXELLENSIS : The Bloodletting Letter of 1539 An Annotated Translation AND Study of the Evolution OF Vesalius's SCIENTIFIC DEVELOPMENT By JOHN B. deC. M. SAUNDERS, F.R.C.S. AND CHARLES DONALD O'MALLEY EDITORS WM. HEINEMANN · MEDICAL BOOKS · LTD. LONDON ACKNOWLEDGMENT WHILE the manuscript of this translation was in the hands of the editor, we learned from Professor John Fulton that the Venesection Epistle had been trans- lated many years ago (c. 1908) at the instigation of the late Dr. Harvey Cushing, by Professor Charles Upson Clark of Toronto, Canada. It was Dr. Cushing's inten- tion to publish Professor Clark's version with annota- tions and a preface on its relationship to the Tabulae Sex. Professor Clark's translation is now in the Cushing Col- lection of the Yale Medical Library ("The Harvey Cushing Collection of Books and Manuscripts," New York, 1943, item V74) and through the generosity of the translator and Professor Fulton, has been made available to us. With great magnanimity, Professor Clark has given us permission to utilize his version in any way we thought fit. The two versions agree remarkably closely. Where we disagree (usually on technicalities), we have had the invaluable opportunity of rechecking the trans- lation, and where we have felt that Professor Clark's rendering better expressed the meaning, we have not hesitated to adopt it. We should therefore like to ex- press our great thanks to Professor Clark for his gracious gesture and we hope that he will feel a measure of per- sonal interest in this translation. ANDREAS VESALIUS BRUXELLENSIS: THE BLOODLETTING LETTER OF 1539 By John Β. deC. Μ. Saunders and Charles Donald O'Malley* INTRODUCTION T HE letter on venesection of Andreas Vesalius of Brussels, al- though a minor work, completely overshadowed by the mag- nificence and power of his masterpiece, De humant corporis Fab- rica, is never the less a valuable historical document. It should not be forgotten that despite his attacks and criticism, Vesalius was and remained intellectually a Galenist, fully conditioned by the struc- ture and scholastic thought of his epoch, enmeshed in the difficul- ties which the lack of a clearly formulated scientific method had woven. 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 prin- ciples based solely upon the power of the intellect, were enshrined as truth. The venesection letter is therefore transitional, occupying the period of his scientific adolescence, bridging the interval be- tween the frankly Galenical anatomy of his earlier recension of Guinter's lnstitutiones Anatomic ae, 1538, and the observational method which made the Fabrica (1543) the first positive achieve- ment of modern science. Vesalius's fame rests upon his anatomical contributions, but he was as fully concerned with the problem of practical medicine. We believe that such statements that "he is the first real specialist, for with but little digression he devoted himself to one branch of med- icine, to anatomy,"1 tend to give a false impression of his develop- ment and ignore the source which provided both his impetus and his limitations. Indeed it was his ambition to master the whole of medical science, and the preface to the Fabrica2 evidences his great * From the Division of Anatomy and the Department of Medical History and Bibliography, University of California Medical School, San Francisco and the History Department, Stanford University, California. ι. D. Riesman. The story of medicine in the Middle Ages (New York, 1935), p. 196. 2. Fabrica (1543), "Preface," f. *2V. 6 SAUNDERS & O'MALLEY concern over that separation of medicine and surgery which Ara- bian and theological influences made a characteristic of his age. For him, anatomy is but an essential preliminary which will serve to re- unite all branches of the healing art. The relegation of manual pro- cedures to the barber-surgeon calls forth his most acid condemna- tion. Medical practice and especially therapeutics he studied with passion as is everywhere apparent in his writings. Apart from the present letter, they form the subject of his first work, a recension of the treatises of Rhazes to the King Almansor, De Singularum Corporis Partium Affectum Curatione, 1537; make up a large part of his Epistola rationem modumque propinandi radicis Chynae decocti (1546) and constituted the bulk of those works which he destroyed in his anger resulting from the criticism of his erstwhile friends and colleagues.3 The venesection letter strongly suggests that it was Vesalius's preoccupation with such clinical problems which provided the in- sight that enabled him to shake off the dead hand of Galen's pro- nouncements and made the production of the Fabrica possible. Vesalius tells us that any such discrepancies in the Galenical anat- omy which he had observed, he had noted in the Institutiones An- atomicae (1538), with uncertainty and trepidation. The Tabulae Sex (1538), great advance in anatomical illustration though they be, show all the characteristics of the old anatomy. "The plates are in fact Galen's" is Singer's judgment,4 "well and diagrammati- cally portrayed." However in the second of these plates is a mild criticism of Galen in connection with the origin and distribution of the vena azygos together with some remarks on its relationship to venesection in dolor lateralis (pleurisy). This is the theme which is elaborated in the following year, 1539, and forms the content of the present communication to his friend and mentor Nicolaus Florenas. Since remote antiquity, venesection has 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 commen- tary had exposed how far current practice had deviated from the teachings of Hippocrates and Galen. Armed with the new learn- ing they sought not only to defend the purified classics against the 3. Epistola Chynae, p. 196 (for 195), f. BG21:. 4. Charles Singer, The evolution of anatomy (New York, 1926), p. 114. Andreas Vesalius Bruxellensis: 7 onslaughts of the Arabists, but with subtle dialectic each attempted to uphold the Tightness of his textual criticism. Barren and sterile though this controversy may have been, none the less 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 humor- al doctrine and every measure directed toward the practice of phle- botomy depended upon the opinion of Galen for its anatomical in- terpretation. 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 find- ings 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 infalli- bility of the Prince of Physicians. The emancipation of Vesalius begins with the venesection letter. The chain has been broken at its weakest link and, what is of the greatest importance, on the eve of preparations which foreshadow the writing of the Fabrica, "if," as he says, "the opportunity of bodies offers, and Joannes Stephanus [Van Kalkar], outstanding artist of our age, does not refuse his services " 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 mas- ter, Sylvius. We know little or nothing of the origins of venesection as a therapeutic procedure. It has been suggested that the practice arose in primitive folk-medicine from conceptions as to the beneficial in- fluences of periodic blood loss in menstruation or to the revulsive effects of accidental haemorrhage.6 The first textual records of any significance are to be found in the Hippocratic collection in the form of scattered references, sometimes contradictory, which give the impression that the procedure had long since passed into standard practice. There is no work, however, either in the so- called authentic books or in the rest of the collection, devoted in whole or in major part to the subject. Hippocrates recommends venesection as both a therapeutic and 5. F. H. Garrison, An introduction to the history of medicine (Philadelphia, 1929), p. 29. 8 SAUNDERS & O'MALLEY prophylactic measure. Although employed in the treatment of a large variety of maladies, the primary indication appears to have been the acute diseases. We are told to "Bleed in the acute infec- tions"6 and that in "Hypochondria . . . strong pains of the liver, heaviness of the spleen, and other phlegmasiae and intense pain above the diaphragm, diseases connected with collections of hu- mours, . . . venesection holds the first place in conducting the treatment."7 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 disease8 and one of the "acute affections," but venesection is to be employed only when the pain is above the diaphragm.9 An admonition of such importance that it is repeated a little later in the same work.10 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 au- thors as dolor lateralis. It has been assumed by both sixteenth-cen- tury and modern writers that the disease so described is pleurisy or some allied pulmonary disease. There can be little doubt that pleu- risy is, even in classical times, usually implied by this phrase. Vesa- lius,11 however, interprets the expression, and we believe correct- ly, 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 consider- ations of the humoral pathology. In this view, Hippocrates' teach- ing was that one should let blood in pleurisy but not in other forms of dolor lateralis occurring below the diaphragm. The interpreta- tion of dolor lateralis as pleurisy alone consequently gave rise in later times to great confusion and dispute as to the rationale of its treatment. In the employment of venesection as a prophylactic measure, Hippocrates mentions astronomy and meteorology as a source of prognostication,12 based on the recognition that certain diseases are more apt to occur and to be exacerbated at certain seasons of 6. Regimen in acute diseases, "appendix," sect. 2. 7. Ibidem, "appendix," sect. 3. 8. Airs, waters, etc., sect. 3. 9. Reg. acute dis., "appendix," sect. 7. 10. Ibidem, "appendix," sect. 11. 11. Text, pp. 54 ff. 12. Airs, waters, etc., sect. 2. Andreas Vesalius Bruxellensis 9 the year.13 The two solstices, especially the autumnal, are particu- larly dangerous.14 One may expect the acute diseases in a summer of drought and a summer preceded by a dry cold winter, and a rainy spring will bring the acute fevers, ophthalmia and dysen- teries.15 The winter is the time of pleurisy and pneumonia.18 Such views on meteorological medicine gave the authority of the "Father of Medicine" to the extraordinary astrological beliefs of later times. Elaborated by Galen in his work on the critical days, De diebus decretoriis, embroidered by the Arabs, these beliefs particularly affected the practice of phlebotomy and engendered the familiar calendars of blood-letting. Hippocrates recognised that certain diseases were most preva- lent according to age; the young to haemoptysis, phthisis, acute fevers and epilepsy17; those of mature age to asthma, pleurisy, pneumonia, haemorrhoids, etc.18; and those of advanced age to a multitude of complaints.19 Moreover, apart from seasons, certain conditions of locality are conducive to, and certain types of men are subject to pleurisy.20 In respect to the general procedure of venesection, it must be noted that the season of the year had to be taken into account, the spring being most advantageous.21 One should ascertain that the patient "is in the prime of life"22 although precisely what were the age limits is not clear. As we shall see from Galen, venesection was proscribed for children. Furthermore, "venesection is to be prac- tised when the person has dined more or less freely and drunk, and when somewhat heated, and rather in hot weather than in cold";23 but after venesection a certain amount of restriction in fluids and diet was enjoined.24 It is most important not to perform venesec- tion in a patient lacking strength. "Bleed... if they have strength"25 and again, "if he... is strong."26 13. Aphorisms, πι, 19. 14. Airs, waters, etc., sect. 11. 15. Aphorisms, 111,7,11. 16. Ibidem, πι, 20-22. 17. Ibidem, πι, 27, 29. 18. Ibidem, HI, 30. 19. Ibidem, HI, 26, 27, 31. 20. Airs, waters, etc., sect. 4. 21. Aphorisms, iv, 47, 53. 22. Reg. acute dis., "appendix," sect. 20. 23. Ulcers, sect. 16. 24. Reg. acute dis., "appendix," sect. 24; Ulcers, sect. 14. 25. Reg. acute dis., "appendix," sect. 2. 26. Ibidem, "appendix," sect. 20. IO SAUNDERS é Ο" M ALLEY Hippocrates gives almost no instructions on the technique of venesection. He warns that in bleeding by scarification, pressure must be avoided lest contusion be produced. The incisions are then washed with vinegar and no clot allowed to remain between the lips of the wounds as inflammation may ensue. Finally the wound is dressed with wool previously soaked in wine and oil. If after cupping the blood continues to flow, the instrument must be re- applied before the wound heals. The Hippocratic tradition of therapeutic bleeding was carried on by Diocles of Carystos27 and his pupil Praxagoras of Cos to in- fluence the great Alexandrian anatomist Herophilus. Herophilus employed venesection especially when he desired to stop a haem- orrhage28 and modified the Hippocratic view with regard to the treatment of pleurisy in that he established a general rule never to bleed after the fifth day of the disease.29 In his therapy he favoured the more drastic measures and his meddlesome tendencies led to an excess of venesection. On the other hand Erasistratus, his con- temporary, followed the views of his teacher Chrysippus, the ex- ponent of the rival school of Cnidus, who rejected phlebotomy doubtless because like the Pythagoreans, he placed the seat of the soul in the blood. "Chrysippus the Cnidian," says Galen, "con- sidered phlebotomy ought to be removed altogether from our means of cure."30 In its place he substituted a regimen of strict di- etary control. Caelius Aurelianus tells us that Erasistratus did, how- ever, practice venesection to a limited extent but that his disciples completely discarded the procedure.31 Such divergences of opin- ion began the long, acrimonious and futile controversies of Roman times; Erasistratean methods extending through Asclepiades of Prusa to the more temperate therapy of Celsus and the Herophi- leans to the drastic pharmacy of Galen. It remained for later writers, notably Galen and Antyllus, to enlarge and comment up- on venesection. Antyllus's writings are known only through such parts as survived in the pages of the encyclopaedists whereas ac- ceptance of Galen as the exponent and commentator upon the "Father of Medicine," apart from his philosophical system, assured his dominating position. Generally speaking we may say that Galen explains the therapeutic indications of venesection and An- tyllus, the operative procedures. 27. Galen, De ven. sect. adv. Erasis. 5. 28. Cael. Aurelianus, Acut., π, 13. 29. Idem, Acut., π, 21. 30. De curandi per ven. sect., 2. 31. Cael. Aurelianus, Acut., 11, 13. Andreas Vesalius Brwcellensis I I According to Galen, the diathesis which had most need of vene- section was plethora or plentitude, the quantitative ascendency of the humours in their original or normal proportions. Elaborating on Hippocratic conceptions currently in dispute, he exhorts his read- ers to recognise the reality of two kinds of plethora; that affecting the strength and that related to the content of the vessels8.2 The first of these occurs when the quantity of the humours is great enough to overwhelm the strength, either because of their super- abundance alone, or because of persisting "weakness of strength." This syndrome is indicated by a feeling of heaviness and difficulty in movement. The second variety occurs when the humours by their increase distend the vessels or merely surpass the measure of the normal quantity and give rise to a feeling of tension, soreness or pain. As either type may exist in health or in disease and may be either local or general, we are provided with the necessary justi- fication for the use of both prophylactic and therapeutic venesec- tion as well as its local and general application3.3 The terms plethora (πληθώρα) and plenitude (πλήθος) are usually synonymous and with- out distinction.84 Galen defines plenitude as "the superabundance of humours in the entire body of the animal" but on occasions re- serves the term, plethora, exclusively for that kind of plenitude affecting the capacity of the vessels.35 There is however another kind of humoral redundancy, known as cacochymia, in which there is either the quantitative ascend- ency of a single humour and proportional imbalance or the humour is qualitatively altered "When all the humours have augmented in the same proportion, this state is called plenitude or plethora; but when the body is filled with yellow or black bile, phlegm or serous liquid, such a diathesis is not called plethora but cacochy- mia."86 The theory of plethora is a fundamental point in the system of Galen. He devoted a special treatise, De plenitudine, to the sub- ject and returned to the topic again and again, in his extensive works. It constitutes the basis of the whole rationale of venesec- tion on which Vesalius's argument rests. Likewise the distinction between a superabundance in equal proportion of all the humours and the quantitative or qualitative ascendency of a single humour 32. De plenitudine, 2. 33. De plenitudine, passim. 34. Methodus medendi, xiii, 6. 35. De plenitudine, 6; Adversus Julianum, 7. 36. Meth. med., χιιι, 6. 12 SAUNDERS & O'MALLEY should be noted, especially since, with the revival of Greek medi- cine in the sixteenth century, it was regarded as of supreme mo- ment. The plethoric state, Galen contends, requires evacuation to rid the body of excess humours for the excess may settle in some or other part of the body, causing inflammation, and there undergo corruption. But it is not always necessary to draw blood, as purga- tives, baths, frictions, sweating, and even walks, suffice for evacua- tion. There are precise indications, relating to the state of health or sickness, which determine the method to be employed. One must take into account the quantity and quality of the plenitude, the age, strength, and natural complexion of the patient as well as the season, locality and the constitution of the air. There are, in addi- tion, special circumstances which decide whether or not one can draw as much blood as the sickness in itself allows3.7 Galen's main rule, governing the use of or abstention from venesection, would seem to be so-called "integrity of strength."38 There are three kinds of strength dependent upon the three prim- ary faculties, animal, vital and natural, and therefore psychic strength which resides in the nervous system and rules the acts submitted to the will, vital strength derived from the heart and vessels, which controls the movement of the blood, and natural strength which has its point of departure in the liver and governs nutrition. "When the strength is intact, and there are signs of plethora, and in addition, when an inflammation exists of what- ever cause, and it is a question, above all, of plethora in regard to content, then one must bleed without making any other distinc- tion, that is without regard to the locality, the season and other cir- cumstances "39 Galen's sole exception to this rule is age; child- hood and old age, but especially childhood, are a contra-indication in regard to venesection.40 The evacuation of the redundant humours may be carried out in two ways, known as revulsion and derivation. These methods, ac- cording to Galen, were invented by Hippocrates,41 but they are referred to very obscurely in his writings. For the modern reader, the precise meaning and significance of these terms, and particu- larly of the theory underlying the rationale of their employment in 37. De curandi per ven. sect., passim. 38. De curandi per ven. sect., passim. 39. De curandi per ven. sect., 20. 40. Ibidem, 9. 41. Meth. med., ν, 3; Ad Glauconem, π, 4.