Death of Vesalius: more evidence points to scurvy*

Το κείμενο θα μεταφραστεί στα Ελληνικά προσεχώς.

Venetian ship by Kryštof Harant, 1598.

Over a year ago, after a short period of research, I suggested that Andreas Vesalius, the Flemish founder of modern Anatomy, must have died from scurvy. I return to the subject now, with more evidence, to strengthen the case I made then. In order to fully appreciate the information and the arguments presented here it is necessary for the reader to have read my earlier work. However, I provide a summary for those who would only like to be reminded of the main points.

***

It is generally accepted that Vesalius died in Zakynthos, in the middle of October 1564, while returning from a pilgrimage to the Holy Land.  Only two eyewitness accounts of his death exist and both have been looked upon with a degree of suspicion. Perhaps the most widely known is that of the Italian Pietro Bizzari, based on what he was told by an anonymous Venetian goldsmith. The goldsmith claimed that he had happened upon the sick Vesalius by chance on a deserted beach and, in spite of the opposition he had faced from the Zakynthians, had tried to assist him in his final hours and had buried him with his own hands in a plot he had purchased for that purpose.

The other account is that of the Frenchman Jean Matal, better known as Johannes Metellus, who was given the information by Georg Boucher, a German from Nuremberg. Boucher claimed he had met Vesalius in Egypt. Zakynthos was the first land they reached after a terrifying journey of forty days. As a result of food and water shortage several persons on board the ship had fallen ill and some died. The famous anatomist, poorly supplied with provisions, fell ill, initially with worry over the breakout of the disease and his own fate. Soon after disembarking Vesalius dropped dead and Boucher arranged for a stone to be put on his grave.

Some writers have tried to construct a story by combining the two accounts, others invented dramatic details like a shipwreck, however, the fact remains that these are the only two testimonies in existence. Moreover, they cannot both be true.

I put forward that the information Bizzari was given by the goldsmith is fictitious from beginning to end for the following reasons:

1)  It is too vague. There is no mention of the date, any specific locations, the circumstances by which Vesalius, having fallen ill whilst on the island, ended up alone and sick on a deserted beach, what his illness was or at least some of its symptoms.

2)  There is no mention of Vesalius’ ship or fellow travellers. The goldsmith gives the impression he was abandoned. However, if such a famous nobleman was abandoned and had died helpless it would have been a major scandal with serious repercussions.

3)  The goldsmith and Bizzari display complete ignorance of the quarantine arrangements on the island and of the constant monitoring of the coastline by local horsemen, who reported to the Venetian authorities. In fact the story completely ignores the existence of authorities and gives the impression the island was governed by a mob of locals who did as they pleased.

4)  The goldsmith’s story conflicts with the testimonies of the German Christoph Fürer Von Haimendorff, who visited the island in 1565, and of Giovanni Zuallardo (Johannes Schwallart), a compatriot of Vesalius, who visited in 1586. They both spoke of Vesalius’ grave in the Franciscan monastery of Santa Maria delle Grazie. Von Haimendorff gave the burial inscription. Zuallardo did not see the inscription because, as he informs us, it had been looted in the Turkish attack of 1571.

5)  The motive for the concoction of the story is all too obvious. The goldsmith wanted to present himself as a hero.

In the story that Boucher narrated to Metellus there are neither contradictions nor the obvious self-promotion of an attention-seeker. However, as one might expect, there is not enough detail and there are omissions and some points of ambiguity. More importantly, some of the details of this account are so strange that they are difficult to believe. In my previous work I suggested that this version of events is, in spite of the extraordinary circumstances it describes, explainable and consistent with other evidence, and, hence, credible.

In particular:

1)  It gives the month in which Vesalius died as October, which agrees with the inscription given by Von Haimendorff and other evidence.

2)  It gives the location of Vesalius’ death as the gate of the city of Zakynthos. This is compatible with a burial in Santa Maria delle Grazie.

3)  The mention of a gravestone goes well with the evidence of Von Haimendorff and Zuallardo regarding the existence of an epitaph.

4)  The mentioned symptoms of Vesalius’ illness – admittedly only two and only inferred as such – are fully compatible with scurvy, a disease that hit during long sea journeys. His extreme fear and irrational behaviour, immediately prior to his illness, are well known early symptoms. Metellus simply did not recognise them as such and believed they were causal to the illness. His sudden death at the gate of Zakynthos also matches one of the well documented outcomes of scurvy.

5)  The forty days that Boucher said Vesalius spent at sea, unable to land anywhere, his port of origin in Egypt – which implies he had spent up to a month and a half in the desert prior to his embarkation – his haste to board a ship, all generate the suspicion that his reserves of vitamin C were very low. When one considers the diet of western pilgrims when crossing deserts – the supplies of the well known Felix Faber were given as an example – Metellus’ repeated assertions that Vesalius was not well supplied, the fact that he had been travelling almost continuously since he left Spain in March and the kind of diet one would expect aboard the ships he used, it should have been thought fortunate if he had not displayed at least mild symptoms of scurvy by the time he reached Zakynthos.

6)  Metellus attributes the illness that broke out on Vesalius’ ship, at least partly, to food and water shortages. He is clear though in that the deaths were caused by illness and not directly by starvation or dehydration. He also implies that the mysterious disease did not affect everyone. Boucher, for example, does not appear to have fallen ill at any point. This, combined with the information that Vesalious fell ill only after others had expired, excludes the possibility of contagion. For if the incubation period was short it would have affected at least one person on board in the early stages of the voyage, and thus not given the impression it was caused by food and water shortage. If, on the other hand, its incubation period was long, considering that the first wave of infection became apparent long enough into the voyage for the shortages to have become a serious problem, then the rest of the affected would not have had the time to show symptoms before reaching Zakynthos.

This leaves the possibilities of either a dietary deficiency or contact of some of the passengers with an infectious agent before boarding the ship. Metellus though is unlikely to have considered food and water a factor if illness and death had continued after the arrival at Zakynthos, and there is no infection which is cured by the arrival at a port. Given the dietary habits of the region, namely a staple diet based on wheat, and the outcome of the illness, the only deficiency that could have affected Vesalius is scurvy. Metellus’s story is not only explainable by an outbreak of scurvy but also appears to eliminate any other possibility.

 

A. Vesalius’ symptoms compared

There are two points in my previous article that need to be partially revised in the light of evidence presented here. The first one is my assertion that personality changes are amongst the first symptoms of scurvy. In fact, personality disorders are the very first symptom of scurvy and manifest themselves before the sufferer displays any of the obvious clinical signs. This was shown in a clinical experiment conducted in 1971 (1).

  

The authors used the “Minessota Multiphasic Personality Inventory” to test their sample. The results of the personality changes were demonstrated in Fig. 3 of the study. The changes correspond to the classical “neurotic triad” of the MMPI: Hypochondriasis, Depression, and Hysteria. One can easily notice that their respective curves become elevated before they enter the shaded area, which represents the existence of other signs of scurvy. The MMPI test is now somewhat dated, especially its terminology, but is still valid and in use (2).

It is useful to see how personality changes caused by scurvy were expressed in layman’s terms, and in conditions of real hardship and mortal danger, aboard a ship. Richard Walter of the Anson Expedition of 1740, who had seen nearly all his shipmates go down with scurvy at some point, and the majority of them die from the disease, described the mental state of the sufferers. These are his words (3):  

“This disease is likewise usually attended with a strange dejection of the spirits, and with shivering, trembling, and a disposition to be seized with the most dreadful terrors on the slightest accident. Indeed it was most remarkable, in all our reiterated experience of this malady, that whatever discouraged our people, or at any time damped their hopes, never failed to add new vigour to the distemper; for it usually killed those who were in the last stages of it, and confined those to their hammocks, who were before capable of some kind of duty; so that it seemed as if alacrity of mind, and sanguine thoughts, were no contemptible preservatives from its fatal malignity”.

One does not need to be a psychiatrist to be able to discern clear signs of depression here, and in the phobic/neurotic terrors an aspect of what Kinsman and Hood would have described as hysteria. Let us now remember that Metellus, in both his surviving letters, to Georgius Cassander (4) and to Arnoldus Birckmannus (5), describing Vesalius’ mental state wrote that, when people became sick and the dead were thrown to the sea, he was so greatly disturbed and fearful that he became sick himself. He often implored the sailors to not throw his body to the sea if he died.

Vesalius’ immense worry and fear of falling ill, when he had not yet showed symptoms, point directly to a hypochondriac reaction. One may argue, and there can be no counter-argument, that Vesalius was an extremely intelligent individual and an excellent doctor, and he may well have had good reason to fear. Indeed, he may have noticed, for example, that all those falling ill were from amongst his companions. However, when one considers that Vesalius’ worry and fear were accompanied by the hysterical appeals of a high-ranked nobleman to simple seamen over the fate of his corps, there cannot be much doubt that the heightened level of those feelings was the result of hypochondriasis. Even if one cannot, perhaps, discern explicit mention of symptoms of depression, given the circumstances described who would expect them to be absent?

We see then that Vesalius’ mental turmoil, as described by Metellus, fits in very well with both, the Kinsman and Hood clinical experiment and the description of Richard Walter in actual, uncontrolled circumstances.

Kinsman and Hood do not fail to mention that similar results with scurvy have been observed in prolonged semi-starvation and in deficiency of vitamins of the B complex. However, the prolonged semi-starvation results were observed over a period of several months (6) and, though Vesalius and his companions may not have been adequately provided during their journey, there is no hint of shortages before their departure from Egypt. In addition, it is unthinkable that Vesalius, while half-starved for some reason, would have proceeded to Egypt from Jerusalem rather than return to Europe immediately, or that he could have starved himself because of his supposed avarice.

Of the B vitamins only deficits in B1 (thiamine) and B3 (niacin) cause potentially fatal conditions: beriberi and pellagra respectively. Outside specific groups, such as alcoholics, outbreaks have been observed in very poor populations, whose diet consisted mainly of polished rice in the case of beriberi, or maize in the case of pellagra. There is no conceivable reason why a group of wealthy western pilgrims, whose diet consisted, to a large extent, of wheat and meat products, both of which contain the required B vitamins, would suffer a lethal outbreak when malnourished for fewer than 40 days.

Death from scurvy cannot be studied in a clinical experiment for obvious reasons. Yet, there are plenty of descriptions of such deaths in actual circumstances. One of the most interesting is again from Richard Walter:

“... and others, who have confided in their seeming strength, and have resolved to get out of their hammocks, have died before they could well reach the deck; nor was it an uncommon thing for those who were able to walk the deck, and do some kind of duty, to drop down dead in an instant, on any endeavours to act with their utmost effort, many of our people having perished in this manner during the course of this voyage.”

The similarity of this description with Vesalius’ sudden collapse and death, after the effort of disembarkation and approach of the city gate, is remarkable.

 

 B. From the perspective of a 16^th century expert on scurvy

The second point I made that needs to be partially revised is that scurvy did not have a name yet at the time of Vesalius’ death, even though I believed the disease was known to Metellus and his correspondents. It is correct that the term scurvy was only just becoming established as the name of this terrible “new” disease within a narrow circle of physicians but Metellus was probably familiar with it. In fact, his good friend Johannes Echtius, the person who was present when Georg Boucher narrated to him the events that led to Vesalius’ death, was the very man who had coined that name 23 years earlier.

From the Vesalius bibliography I had hastily formed the opinion that the meeting with Boucher was very much a chance encounter at Cologne, where both his interlocutors lived. There is no hint that Boucher was in Egypt for a pilgrimage and it is likely he was a merchant. His business interests could well have brought him from the Nile to the Rhine, where Cologne was one of the major centres of the German speaking Europe. However, on finding out more about the personalities and work of the two friends, serendipity lost its appeal.

Metellus, who had studied law and is better known as a cartographer, was the nearest thing 16^th century Europe had to a press agency. A Frenchman who had lived in Italy and England, Metellus had a wide network of correspondents in several countries, with whom he exchanged information on subjects that went beyond the law and the globe’s exploration. Theology, politics, publishing and philosophy are the usual topics but a letter to Georgius Cassander, the well known theologian who was also the addressee of one of Metellus’ letters describing the death of Vesalius, reveals a keen interest in medicine too (7).

Cassander was suffering chronically with what may have been rheumatoid arthritis and a year before Vesalius’ death Metellus sent him a rather long epistle with information and instructions on the use of zarzaparrilla. It is a plant that had been introduced from the Americas by the Spanish and was believed to not only relieve joint pains but also to cure syphilis, which was, like scurvy, another new and major problem that had appeared with the onset of the Age of Exploration. In this letter Echtius, and his correct opinion on the matter, are mentioned, leaving no doubt about Metellus’ high opinion of his medical expertise.

Echtius was indeed a much respected physician and, like Metellus, a humanist: an ardent admirer of ancient Greece and Rome. For him all answers could be found in classical antiquity and every new discovery had to be filtered through the old texts. In humanist minds even zarzaparrilla, a New World plant, had to be known to Dioscorides, the Father of Pharmacy. It is not clear what exactly the pair made of Vesalius, who had dared defy Galen, but, though they were unable to deny his indisputable knowledge of human anatomy they would have been very unlikely fans.

Echtius’ humanism did not prevent him from striving to learn through his own observations and the observations of others. It only meant he sought explanations in the ancient texts rather than the knowledge of how the human body works, knowledge he did not possess anyway. In 1541 he was the first to write a treatise on the new mysterious disease and in this he gave it a name: Scorbutus (8). The word was a Latinisation of the Danish word scorbuck and Echtius identified it as the Stomacace (Στομακάκκη) and Sceletyrbe (Σκελοτύρβη) that had been first mentioned by Strabo (9). As their names suggest, Stomacace was a complaint of the mouth and Sceletyrbe a complaint of the legs, making the symptoms of the twin diseases resemble those of scurvy. They had afflicted a Roman army under the command of Aelius Gallus, prefect of Egypt and a friend of Strabo, in Leuce come – a location believed to be by the Red Sea, just south of Sinai. These “local diseases” had been attributed by Strabo to “the waters and the plants”. 

Believing that the disease was known to the ancients, Echtius used the writings of Celsus and Galen in order to describe scurvy as a disease of the spleen. According to Galenic theory the spleen eliminated the melancholic humour, or black bile, that was formed in the liver. An enlarged and diseased spleen would create breathing problems, as it had been observed in scurvy, and the black bile would accumulate and create dark spots under the skin, another sign of scurvy. It is remarkable that Echtius did not, like so many later doctors, miss the depressed mood of the sufferers, even though he did not see it as a symptom: a sad, melancholic person, that is someone with excess black bile, was at risk from scurvy and someone troubled by worries could develop it. However, he also gave other causes, as we shall see a little later, which explained how under certain circumstances anyone could be affected.

It is almost certain that the meeting between Georg Boucher and the two friends, the “correspondent” Metellus and the “scurvy expert” Echtius, was not an entirely chance one. To some degree the pair sought to interview him. How much design exactly is hiding behind this interview is open to speculation. We know that the news of Vesalius’ death had reached London and Paris before the end of 1564. It must have become known in Cologne well before the winter was over. Did Metellus and Echtius take advantage of a business trip by Boucher and arranged a meeting? How much of a coincidence would it be if Boucher’s first trip after his traumatic journey from Egypt, as soon as the winter snows had melted, was to where Echtius lived? Did Metellus and Echtius go all the way to Nuremberg to find him perhaps? It was more than 400 km, several days travel by riverboat and horse. How interested was Echtius in Vesalius’ death and why? Was it only because of his fame or was it related to his cause of death? Why was Metellus so keen to record the events on paper to people who, like him, lived in Cologne? Why did he so pressingly promote his own interpretation of the deeper reason for Vesalius’ death but without naming the disease or intentionally mentioning any of its symptoms?

It is not possible to give answers to those questions with any certainty. We are given though the rare opportunity to test the notion that Vesalius died from scurvy against the knowledge and beliefs of a “specialist” of the era. If Echtius and Metellus knew, or believed, that Vesalius had died from scurvy then we should expect the causes and symptoms that we extract from the letters of Metellus to be in agreement with what Echtius believed were the causes and symptoms of scurvy. Of Vesalius’ symptoms we are only made aware of two: his mental state and his sudden death. His mental state, however, Metellus named as a cause, therefore we will compare it with Echtius’ causes. With regards to sudden death, Echtius, in his treatise, says that “(Scurvy) turns into fatal dysentery, but many times it stops suddenly with a deadly fainting” (10). He was therefore familiar with this type of fatal outcome of scurvy and this may account for Metellus’ “matter of fact”, unsurprised statement that Vesalius simply dropped dead while walking.

Echtius enumerates the following causes of scurvy (11):

1)  Bad diet, like that of the sailors. He advises against meats preserved for a long time by smoking or salting, rotten meat, mouldy biscuit and other similar. In addition, the use of tainted water when there is a shortage of drinking water, especially in hot weather, which quickly spoils it.

2)  Warm air, which disperses the finer parts of the blood and creates clots.

3)  Lack of sleep (vigils).

4)  Manual work.

5)  Concerns (anxiety, worries).

6)  Previous fevers, because, according to Galen, some of them create melancholic humour.

For 2) to 6) he explains that these can generate melancholic humour, which is the cause that produces this disease, even if the diet has not been bad (12). In other words he claims that each of these causes, on its own, is enough to cause scurvy. Based on this we can conclude that Vesalius’ extreme anxiety, to the point of mental anguish or illness, would have been enough to give him scurvy. However, Metellus mentions a second cause of Vesalius’ illness, in addition to his mental state: the shortage of biscuit and water, combined with the fact that his personal supplies were inadequate, or of bad quality, or both. This has to be considered, and compared, not only because it played a part in Vesalius’ illness but also because it is the sole reason given for the illness and death of others on the ship.

It is evident that the shortage of water, perhaps not only for drinking but also for cooking, is covered by the causes in Echtius’ treatise. However, the shortage of food appears to be missing. Should this be taken as an indication that Metellus and Echtius believed Vesalius was killed by a different disease? I think not. The shortage of water is mentioned because it forces people to resort to drinking foul water. Who would have used unclean, smelly water if fresh was available? It is this contaminated water that appears to be blamed for scurvy. A bad diet though is not necessarily the result of a lack of healthier alternatives and that is the reason Echtius does not make explicit mention of it.

The reader does not have to rely on my interpretation of the 1541 treatise. Much closer to Vesalius’ death, the opinion of the existing medical experts unequivocally included food shortage in the causes of scurvy. Johannes Wierus had been discussing scurvy with Echtius at least one year before Vesalius died (13). Four years later, in 1567, he published his own treatise (14). His list of causes is not very different to those that Echtius had written more than a quarter of a century earlier. There, right after the use of corrupt water in shortage of drinking water, he included “fasting with little food of bad juices” (15).

Vesalius neither worked manually nor was part of the ship’s night watch, as no nobleman would, and did not, it seems, contract a fever prior to developing the disease that killed him. He had, however, been sailing in a warm part of the world, went short of food, which probably forced him to eat reduced rations of mouldy biscuit, went short of water, which must have made him use stale, and suffered mental anguish. In the eyes of any 16^th century physician who claimed to know a lot about scurvy there were several reasons why he could develop it; each one of them individually was enough.

After what I have said I am naturally expected to explain how it is possible for a group of pilgrims to have become so severely deficient in vitamin C that some perished from scurvy.

 

C. Vesalius’ pilgrimage and Vitamin C

Picking dates at the end of the 16^th century as drawn by Kryštof Harant.

 Vesalius is believed to have left Madrid in March 1564. He had large sums of money at his disposal but some of it he lent to noble Flemings to repay him in Flanders. Perhaps it was the safest and cheapest way to move his moveable capital away from Spain, where, it appears, he had no plans to return. Almost a month later he still had not crossed into France. He was delayed by customs and an expensive legal fight at Perpignan. There were arguments with his wife, who a little later headed for Flanders, most likely with another big part of his money.

Vesalius continued to Marseille and from there to Genoa by sea. He must have arrived at Venice sometime between the end of April and the middle of May. It is almost certain he had already left for the Holy Land by the 24^th of May (16). His departure was “around the month of April 1564” according to the information of Pietro Bizzari but the first half of May is far more likely. The journey from Venice to Jaffa could last as little as three weeks if everything went well, and in the opposite direction twice as long, due to the prevailing winds. Because it was not very often that everything went well with the sailings of the era, a four week journey to Jaffa is perhaps a more reasonable expectation.  So Vesalius must have arrived at the Holy Land in the beginning or the middle of June. This is according to the Julian calendar, which was still in use then, so in today’s terms it would be more correct to say in middle or late June.

In this first month of his journey, Vesalius would have had a diet that was extremely poor in Vitamin C. Perhaps the best source of information regarding the diet of pilgrims is Felix Faber, who managed two pilgrimages to the Holy Land and devoted a small chapter of his book to the manner of eating on a pilgrim galley (17). Faber travelled from Venice to the Holy Land eight decades before Vesalius and only slightly later in the year (18).

Rich pilgrims ate even better than the galley commander himself. There was bread or biscuit, panada, cheese, eggs and mutton. On fasting days there was salted fish instead of meat. The only food containing some vitamin C was lettuce salad, served with olive oil (salutucium lactuca oleatum), and this only whenever it could be obtained, which presumably means when they entered a port. I think it reasonable to assume that as the season progressed and as they moved further south even lettuce would have become unobtainable. It would have made very little difference; a cupful of shredded green leaves, the most rich in ascorbic acid part of a lettuce, contains only 3.3 mg (19).

For comparison, the recommended daily intake for a 50 year old male in the USA is 90 mg (20). Though not everybody needs as much, the majority require a mean of up to 60 mg daily. The human body can store only about 20 mg of Vitamin C per kg of body weight or an average of approximately 1500 mg in total. Clinical signs of scurvy appear when this falls to around 300 mg (see Fig. 3).  Because Vitamic C in the body is depleted at a daily rate that approaches 3%, a long term average of around 10 mg daily is the minimum intake that prevents someone from developing symptoms of scurvy.

It is interesting to note that, according to Faber, pilgrims were advised by doctors to avoid fruit (21). This is not surprising, when one considers that Galen, on whose teachings Renaissance medicine was founded, advised against eating fruit. Faber’s own experience was different, as he confesses soon afterwards: he saw men, who would not taste anything unless it was recommended by doctors, fall ill and sometimes die, while others, who ate and drank what they pleased, never became ill and remained cheerful and happy throughout the pilgrimage.

Vesalius’ return sailing from Egypt to Zakynthos would not have been any better in terms of vitamin C intake and, if anything, it seems that it was worse. However, there is a gap of up to three months between those two sea journeys, when Vesalius was on dry land and, even if he was not following a well balanced diet, should, in theory, have been consuming foods that contained appreciable quantities of the essential nutrient. In fact, upon closer examination of the places he may have visited and of the corresponding times of year, we shall see that this is very much in doubt. For Vesalius and any other pilgrims with him – it was usual for pilgrims to travel in groups, even if they only met along the way and spoke different languages – the windows of opportunity would have been very few and narrow.

The red line represents the most likely route that Vesalius would have followed during his Middle Eastern travels and is based on the journey of Felix Faber. The broken lines represent journeys by ship or boat. However, the only places where we have reports of Vesalius are Jericho, near the Dead Sea, and the Egyptian coast, probably Alexandria. Please note that this is a modern satellite image and someone looking from space in the 16^th century would have seen considerably less green, which is today enhanced by irrigation.

 

Andreas Vesalius died on the 15^th of October. This means that, according to Boucher’s story, he would have departed Egypt on the 5^th of September, which corresponds to the 15^th of September in the Gregorian calendar. The usual reason for a Holy Land pilgrim to end up in Egypt was a visit to St Catherine’s monastery on Mount Sinai. Such a visit is also supported by the length of Vesalius’ stay in the area and by a letter sent by Hubert Languet to Kaspar Peucer on the 1st of January 1565, informing him of Vesalius’ death (22). This letter is the source of the well known story, which attributes Vesalius’ pilgrimage to fear of the Inquisition.

The Inquisition story appears baseless and is probably no more than a wild or even malicious rumour. It found fertile ground in Spain, where the motive behind Vesalius’s pilgrimage may have been in doubt (23). However, Vesalius’ declared destination was not doubted and in the letter it is given as Jerusalem and Mount Sinai. This piece of information greatly enhances the credibility of Boucher’s story. It is very unlikely that he had information from Spain, or from anywhere else for that matter, and yet he boldly claimed to have travelled with Vesalius from Egypt. I would like to point out that it also strengthens the case for scurvy in two ways: on one hand through Boucher’s story, which appears to be pointing exclusively at scurvy, and on the other hand directly, since it adds a long journey through the desert to Vesalius’ itinerary.

Felix Faber and his group purchased enough food in Gaza to last them until their arrival to Alexandria, calculating that the journey would take 46 days. Of those, they believed they would spend in the desert no more than 25. The desert trip actually took them 32 days but, regardless, they estimated that they would spend three weeks in Egypt. According to Boucher, Vesalius was in a hurry, so he may have spent in Egypt somewhat less. However, it could not have been any less than 10 days. Just the journey by riverboat from Cairo to Rosetta, at the mouth of the Nile, took a few days. Then he would have to travel to Alexandria, probably by donkey. The pilgrims would have needed rest after their desert ordeal and there were arrangements that had to be made before their departure, customs clearance being only one of them. It is therefore reasonable to place Vesalius in Cairo towards the end of August or in the first few days of September. Please note that from now on I am referring to dates in a modern concept and not in the Julian calendar.

This would have Vesalius in the desert in the heart of the summer. The temperatures he encountered would have been 3 to 4 degrees higher than those experienced by Faber. On a normal afternoon it would have been approaching or even exceeding 40°C in the shade, if shade could be found or created – tortuous for men and animals alike. The only advantage in Vesalius’ case would have been the higher chance of finding water from the previous winter’s rain in the wells and waterholes. The group would have needed longer rest periods though and would have probably travelled a lot by night. This would have made their journey slower and it may have taken them a month and a half.

This period, during which the group would have been subsisting on preserved foods devoid of vitamin C, accounts for up to half of Vesalius’ stay in the Middle East and leaves only his days in Palestine and Egypt to be looked at. In my earlier work I had detailed the supplies that Faber and his group had taken with them from Jerusalem but I had omitted the fact they purchased additional supplies from Gaza. It was more of the same, with the addition of onions. Onions contain very substantial quantities of vitamin C but only when they are eaten raw. Their content plummets when they are boiled and hardly any vitamin C remains if they are sautéed (24). For obvious reasons frying was the preferred way of cooking in the desert. Faber also found plenty of pomegranates and figs in Gaza, of which the former are good vitamin C providers. Vesalius would not have found any because they are not yet ripe in July.

Crossing the desert affected Vesalius’ level of Vitamin C in more than one ways. A clinical experiment during World War II showed that quantities of Vitamin C are lost through perspiration (25). Mickelsen and Keys studied their subjects in conditions similar to those of the Middle Eastern deserts. They found that up to 4 mg of Vitamin C per day were lost, irrespective of dietary intake and of the Vitamin C concentration in the plasma. From the authors’ point of view the findings were not significant. This was a study that focused on the short-term needs and performance of soldiers, whose rations included substantial amounts of Vitamin C. Vesalius on the other hand, visited holy sites and travelled continuously under the hot summer sun for around three months with a restricted Vitamin C intake. For him the accretive loss of 200 or 300 mg was very significant indeed.

To illustrate this let us assume that when he departed from Palestine for Sinai and Egypt the amount of Vitamin C in his body was 900 mg. This is halfway between the maximum level of 1500 mg and the 300 mg scurvy threshold. It is a reasonable assumption given his restricted intake on the ship from Venice and his also restricted intake in Palestine, which will be discussed later. Let us also conservatively assume that his journey from Gaza to Sinai and then to Cairo took 30 days, and his loss of Vitamin C through perspiration averaged 2.5 mg per day. He would have then lost in sweat 75 mg during this part of his pilgrimage.

For his physiological functions he would have used the normal 2.9% of his body’s Vitamin C per day, since ambient heat does not result in any additional demand for Vitamin C (26). Using the exponential decay formula we can calculate that, excluding the losses through sweat, his reserves of Vitamin C would have fallen to approximately 370 mg by the time he reached Cairo (27). If we now subtract the 75 mg lost through perspiration we see that Vesalius’ reserves of Vitamin C would have gone below 300 mg and he may have already been displaying early symptoms of scurvy. These symptoms would have abated after a few days of a diet containing fruit and vegetables because he would have been in the initial stages of the disease. However, once he was again on a ship these symptoms would have quickly returned and his condition would have continued to deteriorate until fruit and vegetables became available or until he died.

 

The Martian landscape of Sinai by Edward Lear in 1849.

It is perhaps ironic that one of the last conversations Vesalius is known to have had was about growing fruit. The Franciscan Custodian of the Holy Land, Bonifacius Stephanus, wrote (28):

Truly the plain of Jericho is beautiful, and if it was cultivated, it would be suitable for the production of fruits of all kinds, something that I have been told by experts in the art of medicine, especially by Andreas Vesalius, the very one who was a traveller with me, and I also learned it from many others of this class. There are all kinds of wonderful wools, and precious wood, called aspalathus, quinces, innumerable Balsam of Mecca trees (Commiphora opobalsamum) are in it.

Bonifacius’ euphemistic description carefully disguises the fact that the area was in his time no more than a wasteland, full of thorny bushes, fit only for grazing the flocks of a handful of Bedouins. There may have been a few quince trees but Vesalius would not have felt their astringent and slightly tangy taste since they are never ripe in July.

George Sandys, who visited in 1610, gives a much more blunt description (29):

“... (the orchards of balsam) now utterly lost  through the barbarous waste and neglect of the Mahometans. Where Ierico stood, there stand a few poore cottages inhabited by the Arabians. The valley about ten miles over, now producing but a spiny grass ...”

William Lithgow, who was there at around the same time, counted the cottages; they were nine (30).

It is no accident there is no mention of the palm trees, for which Jericho was known in antiquity, or the dates, for the quality of which it is known today. “At present there are neither rose nor palm trees in Jericho,” wrote François-René Chateaubriand, who visited in the early 19^th century (31). William Turner, not many years after Chateaubriand, remarked that he did not see a single palm tree along the route from Jerusalem to Jericho (32). He did find jujube trees though, which produce berries with large amounts of vitamin C. Vesalius would have missed out again; they don’t ripen before the autumn.

From Jerusalem, a round trip to Jericho, the River Jordan and the nearby Dead Sea would have taken Vesalius around three days. There is no evidence he travelled anywhere else, though Bethlehem, very close, was an almost compulsory day trip and Hebron was another popular destination. Conditions would not have been considerably different in any of those areas. Most of the four weeks or so that he stayed in the Holy Land would have been spent in the Holy City itself. Many pilgrims spent only one or two weeks there but those intending to continue to Sinai and Egypt stayed longer. They had to gather provisions and find animals and guides for their journey.

Jerusalem was most likely not at its best. George Sandys wrote (33):

“From the top of this Monastery, survey you may the most part of this city: whereof much lies waste; ... Inhabited it is by Christians out of their devotion; and by Turks for the benefite receiued by Christians: otherwise perhaps it would be generally abandoned.”

The area around the city was so rocky and barren that, as soon as the group of Felix Faber left the coastal strip and started climbing the mountains of Judea, arguments broke out between them. Some wondered how Jesus could have chosen to live in such a land (34). Faber wondered too:

But even I said secretly in my heart: see, this is the land that is supposed to flow with milk and honey; but I see no fields for bread, no vineyards for wine, no gardens, no green meadows, no orchards, but it is all rocky, burnt by the sun and parched.

It must have been cursed by God for punishment he decided. William Lithgow, more than a century later, came to the same conclusion (35). But the soil of Judea was not completely unproductive. Now and then, where there were signs of habitation, one could see cereals, olive groves, fig, pomegranate and almond trees, the odd palm tree and even some vineyards, the latter tended only by Christians according to George Sandys (36).

Plan of Jerusalem in 1610.

There may have been figs for a while when Vesalius visited; the first harvest, which does not last long, is around the end of June. There may have been grapes too. In a hot climate they ripen early – Faber had found ripe grapes in Crete at the very end of June – but at the higher altitude of Jerusalem it may have taken them a little longer. Neither figs nor grapes are good providers of vitamin C though; only 2 mg (37) and 3.2 mg (38) per 100 g respectively. If Vesalius obtained his vitamin C solely from those fruits, and even if he consumed 100 g of figs and 100 g of grapes every single day, he still would have been taking only half of the amount necessary to not develop scurvy. He would have been short of alternative sources though, since Jerusalem produced no vegetables. This is expected in such a stony and dry land but it is also confirmed by Chateaubriand (39):

“Vegetables are very dear; they are brought to Jerusalem from Jaffa and the neighbouring villages.”

Jaffa, today’s Tel Aviv, was the fruit and vegetable capital of Palestine. Chateaubriand, however, was in Jerusalem in the autumn of 1806. In the scorching summer heat of 1564, when vegetables would have been hard to find anywhere, it is unlikely Jaffa would have been sending them to the rundown mountain town of Jerusalem. Vesalius could perhaps have tasted the fruits of Jaffa, and received a temporary boost of Vitamin C, when he arrived there by ship in June. There must have been melons, watermelons, peaches and apricots. It is far from certain though that he was able to get his hands on any.

The security situation, never and nowhere satisfactory for the pilgrims, was particularly problematic on that stretch of the coastal plain. Faber and his companions stayed aboard their galleys for days off Jaffa, waiting for the animals and escorts that would take them to Jerusalem. Even with a strong, armed escort they were not safe. The worst ones were the “Arabs”, by which Faber means the Bedouins, but the locals were not much better (40):

And when the Arabs are not in the area the villagers assemble and attack the passing pilgrims, causing many injuries. So the journey from Jaffa to Rama is very dangerous because of these attacks and ambushes by the infidels.

This was in the time of the Mameluks but nothing had changed for the better when Vesalius visited in the Ottoman era. William Lithgow, half a century after Vesalius, passed through the area travelling by land. Jaffa did not contain a single dwelling and there was only a tower, guarding the port. There were towns and villages more inland. By the town of Lod, otherwise known as Lydda, very close to Rama and some ten English miles from Jaffa, his caravan of mostly Armenian pilgrims came under attack at dawn by 300 Bedouins (41). Before their Janissary escort managed to repel the attackers 14 pilgrims had been killed and 30 injured.

Armed escorts, however necessary, were not but a thinly disguised form of racketeering, in which Ottoman officials excelled. Their presence deterred attacks by bandits and religious fanatics but the western pilgrims still had to pay “tributes” and “tolls” to other officials and tribal leaders they came across. The demanded amounts varied according to the officials’ estimate of how much the pilgrim could afford to pay. If Vesalius’ reputation had followed him to the Holy Land, something that is very likely since Bonifacius Stephanus appears to have been aware of it, he would have had to pay a small fortune every step of the way. This alone could explain why he had run out of money by the time he reached the coast of Egypt.

On the day they were attacked, Lithgow’s caravan arrived at a place he calls Berah, hungry and with their food supplies completely exhausted, at four in the afternoon. The locals would not sell them anything:

“Having a little reposed there, giving our Camels, Mules, and Asses some provender, but could get nothing for our selves, from these despightfull Moores, (for what wee carried with us, was all spent) except a little Water.”

Vitamin C deprivation is to be expected in the desert or on a pilgrim ship, and can be contemplated in the middle of the summer in the Holy Land, but it is almost unthinkable in Egypt, well known in the time of Vesalius, as it is today, for the abundance of its fruit and vegetables. Yet, the Land of the Pharaohs features prominently in the history of scurvy. In fact, the first ever description of the disease is believed to be contained in the Ebers Papyrus, an ancient Egyptian medical papyrus dated to the middle of the 2^nd Millennium BC. The first ever description of scurvy that leaves not a shred of doubt about the identity of the disease comes from Egypt too. This happened much closer to our times and, most importantly, the sufferers were not Egyptians but western crusaders in the fertile Nile Delta.

In the 13^th century the 5^th and 7^th Crusades both attempted to take Cairo by advancing from Damietta on the Mediterranean coast. Both were defeated and rampant scurvy is thought to have played a major part in their failure, estimated to have killed between a quarter and a third of the crusaders, many of whom were Vesalius’ compatriots. The possible causes of the outbreaks have not, to my knowledge, been examined by historians and several attribute them to the disruption of the crusader supply lines by the Muslims. However, the testimony of Jean de Joinville, the principal source on the events of the 7^th Crusade, while leaving no doubt about the nature of the disease, at the same time confirms that it started two weeks before the Muslim blockade (42).

“You must know, that we ate no fish the whole of Lent but eelpouts, which is a gluttonous fish, and feeds on dead bodies. From this cause, and from the bad air of the country, where it scarcely ever rains a drop, the whole army was infected with a shocking disorder, which dried up the flesh on our legs to the bone, and our skins became tanned as black as the ground, or like an old boot that has long lain behind a coffer. In addition to this miserable disorder, those affected by it had another sore complaint in the mouth, from eating such fish, that rotted the gums and caused a most stinking breath. Very few escaped death that were thus attacked; and the surest symptom of its being fatal was a bleeding at the nose, for when that took place none ever recovered.

The better to cure us, the Turks, who knew our situation, fifteen days afterward attempted to starve us, by means I shall now tell you.

(...)

By this means all provision was exceedingly dear in the army; and when Easter arrived, a beef was sold for eighty livres, a sheep for thirty livres, a hog for thirty livres, a muid of wine for ten livres, an egg for sixpence,  and everything else in proportion.”

It is obvious that the blockade inflated prices but was not remotely related to scurvy. The real cause has to be sought in the dietary and culinary habits of these western soldier-pilgrims. Delving deeper into these habits exceeds the scope of this article. The events are mentioned in order to show the vulnerability of medieval and Renaissance westerners to scurvy during protracted stays in the Middle East, even when they did not cross its arid expanses.

It must also be pointed out that the celebrated abundance of Egyptian fruit and vegetables was neither extended to all 365 days of the year nor showed an analogous variety, especially in the summer months. This is what William Turner had to say, writing from Rosetta on the 3^rd of July (43):

“We are here in a bad time for fruit, grapes and melons being all that Rosetta can now furnish us with: there are yet no lemons, nor even vegetables.”

And a day and a page later:

“June, July, and August, being the worst months of the year for fruit in Egypt, our provision consisted only of grapes and water-melons.”

If this is all Rosetta could offer in the summer – while built on the relatively cooler Mediterranean coast and on the banks of one of the two branches of the Nile – then the rest of the country could not have offered more. Vesalius, who most likely passed by Rosetta, was in Egypt in early September and it is possible he was already there in late August as mentioned previously. This being a transitional period, between the summer and the autumn, we should first examine the availability of the summer fruit.

The poverty of grapes in ascorbic acid has already been mentioned but melons and watermelons are far richer. The watermelon especially, though not as good a provider of vitamin C as other melons, has always been abundant and popular in Egypt since the time of the Pharaohs. There is also evidence that it was available there at least till the end of October. It is inconceivable that someone who has spent more than a month in the desert, however short of money and relying on his existing food supplies (44), would resist this sweet and juicy fruit. Yet, Vesalius is unlikely to have been tempted. In order to explain this statement we first have to describe the fundamentals of Egyptian agriculture prior to the construction of the dam of Aswan in the 20^th century.

With the exception of a narrow coastal strip along the Mediterranean, Egypt receives effectively no rain throughout the year. Therefore, almost the entire country would have been a sandy desert were it not for the Nile. For thousands of years the Egyptians relied on the river almost entirely for the watering and fertilisation of their fields. The river’s level started rising every year in June, eventually flooding the surrounding fields. The water continued to rise and reached its highest level around the 11^th or 12^th of September, the start of the traditional Coptic year. This is exactly the time when Vesalius was there. In the previous few weeks the Egyptians would have broken the earthen barriers they had built, allowing the water to enter the networks of canals and ditches that watered areas the river would otherwise have not reached. Some of the water was led to artificial basins, protected by dykes, for use after the river had receded. As the waters withdrew, leaving behind a layer of mineral-rich, black silt, the Egyptians proceeded to plant the muddy soil. This worked well, apart from the relatively rare occasions when the flood was either very low or very high.

Fruit trees were often on higher ground, which was not flooded, and had to be watered and fertilised manually, a very laborious task. Melons, watermelons and cucumbers require large amounts of water. In a country where it does not rain they had to be planted very close to the river. Also, being nutrient demanding plants, they needed to be in locations where they would eventually be submerged. At the same time they had to be where they could ripen and be picked before they were covered by the floodwaters. Favourite places were river islands and sloping sandy banks (45), sometimes amongst palm trees to protect them from the fierce Egyptian sun. Regardless of the location, from late August and for several weeks, the melon plots would have been underwater. Almost the entire fertile part of the country was flooded every September (46). Where irrigation canals, ditches and reservoirs existed, other plots would have been planted but these would not produce fruit till the end of October, since it takes well over two months from planting to harvest.

This view from the first half of the 19^th century would not have been very different to what Vesalius saw when travelling through Egypt.

The first autumn fruits though would have ripened by September. It was still too early for bananas and oranges but there must have been pomegranates, lemons, quinces and dates. The first three are sources of vitamin C but did not seem to have always been appreciated by western visitors. One disapproving European pilgrim was the Czech count Kryštof Harant, who visited in the autumn of 1598: “Anyway, we would willingly give all the plentiful lemons and pomegranates for a simple apple,” he wrote (47). Incidentally, his journey back to Venice returns strong echoes of that of Vesalius (48). When he limped to church on Christmas Day, feeling very ill and weak, this very wealthy nobleman was almost penniless and had endured a sea journey of 44 days, in which he had faced storms, inability to enter harbours, cold, thirst and hunger. Harant’s return journey is a massive credibility boost for the story that Boucher narrated to Metellus as it dispels any doubts about its plausibility.

Harant’s fruit complaint was not completely unjustified. Egyptian pomegranates looked good but were of inferior taste and so were the quinces (49). So much that the Egyptians used to import better quality ones from Syria. Even today the Egyptian pomegranates are not highly thought of. Fresh quinces are not that great to eat even when they are good, so they are mostly used for preserves. I think I do not need to comment on lemons. The indisputable king of the Egyptian autumn fruits is the date. Dates are always plentiful in September, so they must have been cheap, and are of agreeable taste. Not as beneficial though as one might think for a man who has spent weeks in the desert: they contain practically no vitamin C (50).

In short, we can justifiably say that Vesalius arrived in Egypt with his Vitamin C reserves very low, at a time of year when there were practically no fresh vegetables available and only a very limited selection of fruit. If he opted to consume only the tastier of the fruits that may have been available, namely dates, grapes and figs, then his reserves of ascorbic acid would have become further depleted. Even if he ate moderate only quantities of other fruit, pomegranates for example, his Vitamin C reserves may have not been raised sufficiently and – unbeknown to him – he would not have been fit to undertake the long sea journey to Venice. I will explain this with an example: if Vesalius’ reserves on arrival were just above the scurvy threshold of 300 mg and he ate daily a generous helping of dates and 100 g of grapes, he would have still needed a large pomegranate every third day just to not fall ill.

An impression of Zakynthos in 1570. The church by the sea is St Nicholas of the Mole, built a few years earlier. Just north of it boats ferry people between the ships and what was then a sandy beach. This may be the spot where Vesalius landed, only to expire soon afterwards. He was buried in the monastery of Santa Maria delle Grazie, no more than a few hundred metres away.

 

Conclusions

In addition to what I had previously written, this article shows that,

1)  All available information on Vesalius’ illness:

a)  makes it closely resemble descriptions of scurvy during sea voyages of past centuries. 

b)  matches modern medical knowledge of scurvy beyond expectation,

c)  is perfectly compatible with the ideas and observations on scurvy of 16^th century physicians who had attempted to study the disease,

What is known about Vesalius’ illness looks like an incomplete description of scurvy from every angle.

2)  An authority of the era, Johannes Echtius, who incidentally created the term “scorbutus”, was present in Georg Boucher’s narration of Vesalius’ fatal journey. It is from this narration we derive all existing information on his illness. The level of Echtius’ interest in Vesalius’ death remains unquantifiable and the exact reason for this interest is not clear, however, his presence cannot remain unnoticed.

3)  Boucher’s description of Vesalius’ last voyage is perfectly plausible since Kryštof Harant’s voyage 34 years later was very similar.

4)  The veracity of Boucher’s claim that he met Vesalius in Egypt is supported by Vesalius’ length of stay in the Levant and his declared intention to visit Sinai as well as Jerusalem. This in turn strengthens the case for scurvy.

5)  Vesalius’s travels and sightseeing during the summer months means that some of his body’s Vitamin C reserves were lost through perspiration. Over the duration of his pilgrimage this could have exceeded 20% of his initial reserves.

6)  There were circumstances that appear to have severely restricted Vesalius’s Vitamin C intake even when he was not in the desert or on a ship. His arrival in Egypt at the time of the inundation of the Nile may be particularly significant. 

Scurvy was not as uncommon in the Mediterranean as one may think. As late as the beginning of the 19^th century foreign mariners attributed their recovery from this illness to drinking water from the tar springs of Keri, in southern Zakynthos (51). The island produced excellent fruit and vegetables, and was a good place to recover from scurvy. If sick Vesalius had been quarantined on his ship he would have been spared the effort of disembarkation until he had sufficiently recovered. Strangely enough, Vesalius’ fame, nobility and royal letters of recommendation may have cost him his life. Not only he was not treated with extreme cruelty by the islanders, as the Venetian goldsmith claimed, but he may well have been killed by the respect and kindness of the island’s authorities.

 

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*  I would like to thank more people than I can mention, many of them fellow Zakynthians, for their encouragement and their contributions to my research on the death of Vesalius. For this piece I would like to make particular mention to the organisers of the Quincentenary of Vesalius in 2014, whose continuous interest has been a constant stimulus; from amongst them, special thanks I owe to Dr Maurits Biesbrouck, who kindly sent me his own excellent transcript of the letter of Metellus to Arnoldus Birckmannus from a poor quality photocopy of the manuscript.

 (1)  Some behavioral effects of ascorbic acid deficiency, by Robert A. Kinsman and James Hood, 1971.

(2)  A good, comprehensive description and additional information regarding the MMPI can be found in an article by Jane Framingham at http://psychcentral.com/lib/2011/minnesota-multiphasic-personality-inventory-mmpi/all/1/

(3)  A voyage round the world in the years MDCCXL, I, II, III, IV, by Richard Walter, 5^th edition, London 1749, p. 101.

(4)  The Latin text from the letter of Johannes Metellus to Georgius Cassander, dated Cologne, 17 April 1565, is from Petrus Bertius’, Illustrium & clarorum Virorum EPISTOLAE SELECTIORES, Superiore saeculo scriptae vel a Belgis, vel ad Belgas, Leyden 1617, pp. 372 – 373.

“Vesalius, certa sponsione pecuniae, quo magis praediues ditesceret; ex Hispania, superiore anno, Hierosolymam profectus est, neque se mercatoribus, sed peregrinis comitem adiunxerat: sibique satis sordide de commeatu et annona providerat. Inde rediens, a quodam Georgio Bouchero Nurembergense, ex Aegypto, civitateque Cayro redeunte, in itinere repertus fuit, quem is ad se pertraxit: ita, ut nauim suam ille, ut se comitem ei iungeret, reliquerit. Totos X L dies tempestatibus acti, terram adpellere cum non possent, ipseque Vesalius nimis tenuiter, prae sordibus, sibi de pane, aquaque providisset, ac multi morerentur, inque mare demum abijcerentur, animi languoribus, ac timore, in morbum incidit, saepe nautas rogans, ne se in mare, si moreretur, proijcerent. Tandem nauicula, Zacynthum adpulit, a qua, cumprimum desiliisset; eam urbem ingrediens, ante ipsam portam, mortuus est: cui, saxum posuit is qui haec refert, eius comes. Hunc exitum, viro alioqui claro, nimius pecuniae ardor dedit: quem, multas in humani corporis partibus cognoscendis litteras extinguere debuisse, tibi videretur.”

Vesalius, with a certain promise of funds, wanted to enrich himself more; from Spain, in the previous year, he set out for Jerusalem, not with merchants, but he joined the company of pilgrims; and for himself he provided quite sordid supplies and food. On his return, he met along the way a certain Georg Boucher from Nuremberg, returning from Egypt and the city of Cairo, who left his ship in order to join him. For 40 whole days they were driven by storms, since they could not steer to the land. Vesalius (had) provided very thinly for himself, considering the bread and water were sordid, and (because) many died, and were finally cast off to the sea, he became ill (through) mental illnesses and fear, frequently beseeching the sailors to not throw him in the sea if he died. Finally the ship was steered to Zacynthos, at which, as soon as he could, he disembarked; he entered the city, (and) in front of the gate he died. So, the person who reports these, his companion, put up a [grave]stone (for him). Such was the end of an otherwise brilliant man, who showed too much warmth to money; in him, who knew much about the parts of the human body, education should have extinguished it, you would have thought.   

Please note that I have used the word “sordid” to translate the words “sordide” and sordibus”. “Sordes” has the primary meaning of dirty and the secondary of inadequate or deficient. I believe Metellus used it to denote both the bad quality and the insufficient quantity of the food and water.

(5)  A manuscript copy of the short letter from Metellus to Arnoldus Birckmannus, dated Cologne 17 April 1565, is kept in the John Crerar Library of Chicago University. The librarians of the Cushing/Whitney Medical Historical Library of Yale University very kindly sent me a scanned photocopy. The transcript was made by Dr Maurits Biesbrouck.

“Nurembergensis quidam refert, proximo mense Octobri, Andream Vesalium Hierosolymis redeuntem obiisse, quod ita acciderit: quum Vesalius lucri cupiditate incensus, minima pecunia data, maximam post suum reditum accepturus, a multis, cum quibus ea de re sponsione quadam convenerat, iter eo suscepisset; sese navi peregrinorum, nimia avaritia, non mercatorum Venetiis, ubi literis Philippi commendatur, perquam tamen hoc aes fave fuit acceptus, commisit, et avare quoque sibi perquam tenuiter de annona providat. In reditu incidit in hunc Nurembergensem ex Aegypto Venetias cogitantem, quem induxit, ut sese comitem relicta sua navi conjungeret, quod lubens homo est eoque propter linguae communionem fecit. Et hinc iterum Vesalius sordide sibi providit: ad totos quadraginta dies acti tempestatibus, quum terram appellere non possent, inopia partim panis bis cocti, partim aqua pre-uti, aliquot inde aegritudines hauserint, ac mortui, in mare projecti. In qua res tantopere Vesalii mentem peredit ut animi angoribus, tum timore inciderit in morbum, saepe rogavit ne, si moreretur, esca piscibus, ut ceteri, exhiberetur. Navis tandem Zacynthum vecta est; postea paulo in mare depressa, Vesalius ut primum ex ea desiliit et ad urbis portam vestigia fixit, plane mortuus in terram concidit. Et lapidem Nurembergensis ille comes pro sepulchro posuit. Haec vero idem iste coram Echtio mihique retulit. Ecce igitur tibi miserabilem hominis praeclari obitum, multis exempla futurum.”

Someone from Nuremberg reports that last October Andreas Vesalius died while returning from Jerusalem. This is how it happened: as Vesalius was fired up by greed, he spent very little money for the journey he had undertaken, though after his return he was to receive a lot, by many, from whom he had accepted a certain promise on this matter; because of great avarice he entrusted himself to a pilgrim ship, not the merchant fleet of Venice, for which he had letters of recommendation from Phillip and where a request for credit would have been looked upon favourably, and also through avarice he provided extremely thinly for himself. On his return he met this man from Nuremberg, returning to Venice from Egypt, whom he induced to join him as a companion, leaving his ship, and who did so willingly because of their common language. Again Vesalius provided for himself sordidly; driven by storms for forty whole days, since they were unable to reach land, several became ill, partly from shortage of biscuit, partly of water for use, and the dead were thrown into the sea. In fact Vesalius’s mind was so much consumed by mental anguish that he fell sick from fear and frequently pleaded, if he died, not to be offered as food for the fish like the others. The ship eventually sailed to Zakynthos; a little after the sea got calm, Vesalius disembarked as soon as he could and walked towards the gate of the city, and dropped dead on the ground. The companion from Nuremberg placed a stone on his grave. The very same man told me these in the presence of Echtius. Consider then how the miserable death of this distinguished man will be an example for many.

(6)  The Minnesota Starvation Experiment, which took place between November 19, 1944 and December 20, 1945 in the USA.

(7)  Petrus Bertius, Illustrium& clarorum Virorum EPISTOLAE SELECTIORES, Superiore saeculo scriptae vel a Belgis, vel ad Belgas, Leyden 1617, pp. 157 – 173.

(8)  De Scorbuto, vel Scorbutica passione Epitome in Daniel Sennert’s De scorbuto tractatus, Wittenberg 1624, pp. 299 – 310 and 2^nd edition, 1654, pp. 181 - 186. It was also published in Balduinus Ronsseus’ De Magnis Hippocratis Lienibus, Antwerp 1564, pp. 25 – 33, with the title De Scorbuto, sive Scorbutica passione Epitome and wrongly attributed to Johannes Wierus.

(9)  Strabo, Geōgraphiká, book 16.

 “εἰς γοῦν τὴν Λευκὴν κώμην κατῆρεν, ἤδη στομακάκκῃ τε καὶ σκελοτύρβῃ πειραζομένης τῆς στρατιᾶς, ἐπιχωρίοις πάθεσι, τῶν μὲν περὶ τὸ στόμα τῶν δὲ περὶ τὰ σκέλη παράλυσίν τινα δηλούντων ἔκ τε τῶν ὑδρείων καὶ βοτανῶν. ἠναγκάσθη γοῦν τό τε θέρος καὶ τὸν χειμῶνα διατελέσαι αὐτόθι τοὺς ἀσθενοῦντας ἀνακτώμενος.”

(10)  “in lethalem dysenteriam commutatus, aliquoties vero desinit subito, ac mortali deliquio animi.”

(11)  “Causse procatarctice. Prima dieta grossa & corrupta, ut in navibus Hollandorum& Phrisiorum: usus aquarum corruptarum in aquarum dulcium penuria, praesertim in aere calido, quo citissime aquae corrumpi possunt: Item caro suilla, a coctura etiam subolida, lardum rancidum, caro venatica putida, pisces grossae substantiae, panis biscoctus aliquanto submucidus, allia, cerevisia mali succi procreativa, carnes, vel pisces, vel quae cunq; alia fumo indurata& sale diu conservata, & id genus reliqua. Secunda, aer ambiens calidus sanguinis partes subtiliores resolvens, relinquam sanguinis massam crassiorem relinquens. Tertia, vigiliae. Quarta, labores. Quinta, curae. Sexta, febres praecedentes; quia, ut inquit Galenus, sunt nonnuli, qui per febriles morbos melancholicum humorem contraxerunt.”

(12)  “Haec possunt generare humore melancholicu, caussam videlicet proegoumena huius morbi, etiamsi prava victus ratio non praecesserit.”

(13)  Balduinus Ronsseus, De Magnis Hippocratis Lienibus, Antwerp 1564, p. 5b. The letter or Wierus to Ronsseus is dated 6^th November 1563.

“Multum & saepe de hac morbo contuli cum doctissimo integerrimoque Medico D. Ioanni Echtio Coloniensi, ut& cum alijs, quorum audiui indicia:”

Discussing much and often this disease (scurvy) with the most learned and irreproachable physician Dr. Johannes Echtius of Cologne, and with others too, I heard these symptoms:

(14)  Johannes Wierus’ De Scorbuto was first published in 1567. It is easier to find in Johann Weyer’s Ioannis Wieri ... Opera omnia, Amsterdam 1660, pp. 883 – 901. The causes of scurvy in p. 887.

(15)  “Item jeiunia, cum exiguo mali succi cibo.”

(16)  The date of publication of the Examen, in the preface of which Francesco dei Franceschi recalls Vesalius’ visit to Venice.

(17)  Fratris Felicis Fabri Evagatorium in Terrae Sanctae, vol. 1, Stuttgart 1843, pp 136 – 137.

(18)  Faber left Venice on the 1^st of June 1483 (Julian calendar) and the sea journey to Jaffa took the whole month. This was Faber’s second journey. The first time he had travelled in the month of July, at the time that the Turks were attacking the city of Otranto in Apulia and the island of Rhodes, which created endless problems and delays for the determined pilgrims.

(19)  Data from the United States Department of Agriculture can be found at: http://ndb.nal.usda.gov/ndb/foods/show/2988?fg=&man=&lfacet=&format=&count=&max=25&offset=&sort=&qlookup=lettuce

(20)  Source: Institute of Medicine of the US National Academy of Science.  http://www.iom.edu/Global/News%20Announcements/~/media/Files/Activity%20Files/Nutrition/DRIs/DRI_Summary_Listing.pdf

(21)  Evagatorium, p. 143. “Communiter enim medici suadent peregrinis, ut caveant a fructibus, a potu aquae, ab aere marino, a piscibus” .

(22)  A manuscript, with the title De morte Vesalii ex letteris Huberti Langueti, scriptis ad D. D. Casparu[m] Peuceru[m], is kept in the National Library of Medicine in Bethesda, near Washington DC (manuscript E 86). I am mentioning this because the very existence of the letter is questioned. I have only seen the text from Adam Melchior’s Vitae Germanorum medicorum, Frankfurt Main 1620, p. 133.

“Fama est, Vesalium esse mortuum. Audivisti procul dubio, eum profectum esse Hierosolymam. Causa istius peregrinationis est mirabilis: ut ad nos ex Hispania est perscriptum. Commissus fuit curae eius quidam vir nobilis in Hispania: quem cum obiisse existimaret: nec satis percepisse causam morbi sibi videretur: petiit a propinquis defuncti, ut sibi liceret cadaver dissecare. Concessum est ei, quod petebat: cumque pectus aperuisset: reperit cor adhuc palpitans. Cognati mortui non contenti eum accusare factae caedis; accusant etiam impietatis apud Inquisitionem; existimantes, se ibi severiorem ultionem consecuturos. Cum constaret de caede; nec facile excusaretur error tam periti medici: voluit omnino Inquisitio de eo sumere supplicium: Alii neque. vixque potuit rex sua auctoritate, vel potius suis precibus eum periculo tanto eripere. Tandem concessus est regi et toti aulae, pro eo deprecanti, ea conditione: ut ad expiandum illud scelus proficisceretur Hierosolymam; et ad montem Sinai. Datae Lutetiae cal. Ian 1565. haec Languetus.”

(23)  There is evidence Vesalius may have used recovery from a feigned illness as a pretext for the pilgrimage and his departure from Spain.

(24)  Data from the United States Department of Agriculture can be found at: http://ndb.nal.usda.gov/ndb/foods/show/3019?fg=&man=&lfacet=&format=&count=&max=25&offset=&sort=&qlookup=onion

(25)  Olaf Mickelsen and Ancel Keys, The composition of sweat, with special reference to the vitamins, Laboratory of Physiological Hygiene, University of Minnesota, Minneapolis, 28 May 1943.

(26)  Austin Henschel et al., Vitamin C and ability to work in hot environments, Laboratory of Physiological Hygiene, University of Minnesota, Minneapolis, 9 May 1944. No differences in the concentration of Vitamin C in the plasma were observed during the clinical experiment.

(27)  The exponential decay function used is y = a(1-b)^x, where y is the remaining amount from an original amount a after time x has lapsed, and b is percent change expressed in decimal form (0.029 in this case). This model is given for illustration purposes only and should not be purported to provide any measure of accuracy. I suspect that it only works well when the body’s reserves are in the region of 300 mg. Also, I am unaware of how exactly an individual’s body would react, what restrictions it may impose, or what priorities it may select under very specific circumstances.

(28)  Liber de perenni cultu Terrae Sanctae et de fructuosa eius peregrinatione [ed. by C. de Tarvisio], Venice 1875, p. 235.

“ Ipsa enim planities Hierico est valde pulchra, et si culta esset, ad producendum apta omnia genera fructuum in ea, ut a peritis in arte medica accepi, praecipue ab Andrea Vesalio, qui ipsam una mecum peregrinates est, ab aliisque quampluribus classis huius itidem intellexi. Reperiuntur omnia genera mirabulanarum, et lignum pretiosum, quod appellant spalato, poma aurea, arbores podobalsami innumerae in ea sunt.”  

Some translate the words poma aurea (literally golden apples) as pomegranates. However, Bonifacius Stephanus mentions pomegranates with their usual Latin name of malorum punicorum in page 205. My own translation is quinces. The golden apple that the Olympian goddesses fought over in Greek mythology may well have been a humble quince.

(29)  A relation of a journey begun Anno Domini 1610, 1621, p. 198.

(30)  The Totall Discourse of the Rare Adventures and Painefull Peregrinations, Glasgow 1906, p. 231.

(31)  Travels in Greece, Palestine, Egypt, and Barbary, During the Years 1806 and 1807, New York 1814, p. 272.

(32)  Journal of a tour in the Levant, Volume 2, London 1820, p. 219.

(33)  See (29), p. 160.

(34)  Evagatorium, p. 232.

“Sed et ego ipse in secreto cordis mei dixi: ecce illa est terra, quae melle et lacte dicitur manare; sed non video agros pro panibus, nec vineas pro vino, nec hortos, nec prate virentia, nec pomeria, sed ecce omnia sunt petrosa, adusta et arida.”

(35)  See (30), p. 191.

(36)  See (29), p. 176.

(37)  Data from the United States Department of Agriculture can be found at: http://ndb.nal.usda.gov/ndb/foods/show/2219?fg=&man=&lfacet=&format=&count=&max=25&offset=&sort=&qlookup=figs

(38)  Data from the United States Department of Agriculture can be found at: http://ndb.nal.usda.gov/ndb/foods/show/2257

(39)  See (31), p. 359.

(40)  Evagatorium, p. 211. “Et quando Arabes non sunt in provincia, tunc in transitu peregrinorum conglomerantur villani, et impetunt exercitum peregrinorum cum multis injuriis. Unde periculosum valde est iter de Joppen ad Rama ob hujusmodi insidias et insultus paganorum.”

(41)  See (30), p. 206.

(42)  Chronicles of the Crusades, London 1848, pp. 432 – 433.

(43)  See (32), p. 346.

(44)  In Jerusalem western pilgrims usually stayed at the Franciscan monastery – including non-Catholics like Lithgow and even haters of Catholicism like William Biddulf. The fact Vesalius visited Jericho with Stephanus makes it very likely that he did too. The food was provided by the monks but the guests were expected to make a generous donation in return. Sandys complains he had to pay “A costly rate for a monasticall diet”. In Cairo some visitors found lodgings with local Christians but others stayed in “khans” and caravanserais. The only thing provided was a roof over their head, not even a mattress on the floor. They had the choice of using the food supplies they had carried through the desert, shopping at the local markets or buying cooked meals from numerous “take-aways” and wandering cooks; there were no restaurants. In Alexandria they normally stayed at a fondaco or funduk, a kind of trading post, where food would have been expensive.

(45)  Edward William Lane, Description of Egypt, Cairo 2001, pp. 36 & 487.

(46)  Karl Baedeker, Egypt: Handbook for Travellers, 1^st part, 2^nd edition, London 1885. In p. 58 a good description of the inundation in the 19^th century is given:

“Egypt is now no longer a vast lake during the inundation as it formerly was, nor does the overflow of the fields take place in a direct manner as is commonly supposed. The water is conducted into a vast network of reservoirs and canals, and distributed as required (comp. p. 71), and special engineers are appointed for their supervision. The whole of the cultivable land is divided into huge basins, in which the water introduced by the canals is maintained at a certain height until it has sufficiently saturated the soil and deposited the requisite quantity of mud. After the water in the river has subsided, that in the basins may either be discharged into the river or into the canals, or it may be used for filling other basins lying at a lower level. During these operations many of the villages are connected by means of embankments only, while others can only be reached by boat, and the whole country presents a very peculiar and picturesque appearance.”

(47)  Paulina Lewicka, Food and Foodways of Medieval Cairenes: Aspects of Life in an Islamic Metropolis of the Eastern Mediterranean, published by Brill in 2011, p. 268.

(48)  Kryštof Harant, Cesta z Království Českého do Benátek, odtud do země Svaté, země Judské a dále do Egypta, a potom na horu Oreb, Sinai a Sv. Kateřiny v Pusté Arábii, chapter 26. http://texty.citanka.cz/harant/toc.html

(49)  See (47).

(50)  Deglet noor dates contain 0.4 mg per 100 g. http://ndb.nal.usda.gov/ndb/foods/show/2217 Medjool dates contain nil. http://ndb.nal.usda.gov/ndb/foods/show/2435

 (51)  The Monthly Magazine, Vol. XII, No 79, London 1801, p. 290. See also Christian Müller , Journey through Greece and the Ionian Islands, in June, July, and August, 1821, London 1822, p. 21.