Κυριακή, 1 Οκτωβρίου 2017

An answer to Theo regarding the death of Vesalius

Three years after my speech at the Vesalius Continuum meeting, where I suggested that scurvy appeared as the only possible explanation to Vesalius’ death, Dr. Rudi Coninx and Theo Dirix published a refutation. Theo is a dear friend and Dr. Coninx has dealt with scorbutic patients in Ethiopia. In addition, Theo is – along with another good friend, Pascale Pollier-Green – the driving force behind the search for Vesalius’ remains. Arguments are always welcome, since they bring us closer to the truth, and are particularly important amongst people with common goals. Here is my reaction.

Quotes have been altered or truncated for brevity.

1.      Vesalius must have eaten well in the Holy Land because he was a nobleman.

The point I made was that at that time of year there was extreme scarcity of foods containing Vitamin C in that area, not that Vesalius was devoid of means or that he was not well looked after by the monks who hosted him.

2.      Vesalius ate the food that protected monks from scurvy.

It did not protect them. There is at least one recorded outbreak of scurvy in a Holy Land monastery[1].  The circumstances were not unusual so scurvy in those monasteries was probably not uncommon.

3.      Scurvy was not uncommon in the area but people were not dying in large numbers.

If they had been suddenly forced to migrate en masse, through desert and sea for three months in Vesalius’ footsteps, there would have been a very large number of deaths.

4.      Liver and kidneys are also sources of Vitamin C.

True, but they are not prime cuts. How many times a month would a nobleman be offered offal? I would say probably none.

5.      Forty days at sea is not long enough to develop scurvy. Symptoms appear after 3 months at least.

This is true for a previously healthy-eating subject of a study. An 18th century British warship could easily have a dozen dead and another 50 sick in less than 2 months[2]. There are many factors such as activity, infections, temperature, stress, smoking and possibly others, like age, gender, weight and genetic make-up. The most important though is the amount of Vitamin C in the body when the period of deprivation starts. Some historians seem to believe that West European aristocrats would not have fared very well in this field because of their diet. There is an intriguing study by Susan Maclean Kybett that suggests Henry VIII of England, a contemporary of Vesalius, died from scurvy. And he was neither in the Middle East nor at sea. Vesalius had been travelling for seven months prior to his death. Of those, more than two he spent at sea and more than three in arid conditions during the summer. This is how and where he spent the last five months of his life. He could have been affected by scurvy and died even earlier than he did.

6.      “Clinical description is typical for scurvy”. This is simply not true.

What is not true is that I ever made the above statement. I am not a doctor and I did not make a diagnosis. I presented a theory based on historical research. What I said is that every single thing we know about this case, not only the few symptoms known to us, either points to scurvy or is compatible with scurvy. At the same time no other illness fits the picture. I also made two more observations. First that the sources, which do not name the disease – scurvy had no universally accepted name yet – and do not consciously describe its symptoms, do give a number of causes for it, all of which feature in a list of causes of scurvy in the treatise of Johannes Echtius. Second that the fact Echtius took the trouble to meet Georgius Boucherus – the man who travelled with Vesalius and paid for his burial – and hear for himself the details of what happened is probably not coincidental.

7.      Vesalius would have recognised the symptoms of scurvy and described them.

We have no description of the disease or its symptoms by Vesalius. There is no reason to believe that Vesalius would have described symptoms of scurvy but not of the plague or of cholera for example. All sources are unfortunately silent on the symptoms. His mental state and his sudden death were only mentioned because they were unusual and impressive events, and in the case of the former also as a factor that contributed to his illness. I am the one who considers them as symptoms of an illness.

8.      Echtius’ treatise was only published after his death in 1556.

This is incorrect. Echtius was alive almost a decade after that and heard Boucherus describe Vesalius’ death with his own ears. The treatise was first published in 1564, the year of Vesalius’ death, albeit was wrongly attributed to Wierus.

9.      Echtius believed scurvy was caused by a blocked spleen, leading to an excess of black bile.

Echtius believed that an excess of black bile (melancholic humour) caused scurvy. He wrote that in addition to eating preserved foods and mouldy biscuit, and drinking foul water, the following conditions led to an excess of black bile: warm air, lack of sleep, hard manual work, anxiety and fevers. Each one individually could cause scurvy even if the diet was good[3]. The reasons for Vesalius’ illness as indicated by the sources are: eating rotten biscuit, drinking corrupt water, hot weather and extreme worrying. Please compare with the list of causes given by Echtius in his treatise.

10.   It is claimed that extreme fear and irrational behaviour … are well known early symptoms [Plessas ]. This is not the case.

I quote Rev. Richard Walter of the Anson expedition, who saw many of his shipmates die from scurvy: This disease is likewise usually attended with a strange dejection of spirits; and with shiverings, tremblings, and a disposition to be seized with the most dreadful terrors on the slightest accident[4].   

11.   This (absence of extreme fear and irrational behaviour) is also the observation of one of the authors (RC) having observed scurvy patients in Ethiopian prisons.

Did any of Dr. Coninx’s patients see other inmates die from scurvy? Did he ever observe one of his patients witness an accident? Were his patients evaluated by a psychiatrist? I would hazard the guess that the answer to all the questions is no. I choose to believe Rev. Richard Walter.

12.   The Italian Pietro Bizzari based his account on what he had been told by an anonymous Venetian goldsmith.

Bizzari’s account is not credible. It clashes with the accounts of three different people, who saw Vesalius’ grave in Santa Maria delle Grazie.

13.   Metellus describes the symptoms of Vesalius’ illness.

No, he does no such thing.

14.   The possibility of rotten food as a cause of death on the ship is plausible.

I hope this is not a suggestion that a great physician like Vesalius could not recognise the symptoms of food poisoning in others. If he did, it would have been possible to identify the particular source and he would not have fallen ill himself. Even if that was not possible they could have resorted to sharing the supplies of the crew, who had suffered no cases of illness. Surely it is best to be malnourished than risk death from food poisoning. In addition, had the cause of death been food poisoning, the sources would not have blamed Vesalius’ worrying for his illness. Finally, since the authors seem to agree that Metellus’ version of events is the most reliable, how is it possible for a man on the verge of death from food poisoning to be walking on the seashore of Zakynthos? Food poisoning as a cause of death is not plausible even though the sources claim the disease was somehow related to food and water shortage.

15.   A 1971 study by Kinsman and Hood which allegedly claims that personality changes are amongst the first symptoms of scurvy.

Why allegedly? I quote from the study: The personality changes occurred at an earlier stage of depletion than the psychomotor changes, which did not appear until obvious clinical scurvy was present[5]. So the study does claim that personality changes are amongst the first symptoms of scurvy, the very first as a matter of fact. According to figure 3 of the study the MMPI T-scores started increasing when the level of Vitamin C in the body was at the equivalent of 761 mg. Clinical signs of scurvy became apparent only when the level went down to 300 mg.

16.   The study’s sample is small, not representative of a general population, based on answering a questionnaire and not observation.

Clinical studies of this nature face obvious limitations. If the authors are prepared to disbelieve the testimony of people who lived in a confined space with many victims of scurvy until the final fatal outcome, it is no wonder they complain about the study. Doubting is their prerogative, however, the way to discredit the study is to either find an error in the data or its interpretation, or conduct their own study and come up with different results.

17.   The quoted personality changes peak on day 107. Certainly not an early symptom.

Do the authors consider a symptom only when it peaks? Is pain not pain until it becomes unbearable?

18.   Elevation of this triad is also found in prolonged semi starvation, and deficiencies of B-complex vitamins.

The study at this point refers to Brozek and indirectly to the Minnesota Starvation Experiment of 1944-45, meaning semi-starvation over many months. It is clearly not relevant here as Vesalius did not face food shortages for more than a few weeks. As for vitamins of the B complex if the authors are ready to suggest that Vesalius may have died from beriberi or pellagra I am ready and happy to argue.

19.   These changes are characteristic of individuals who are physically ill, as the subjects were.

Yes, but in the beginning they did not know that they were ill (no clinical signs). Besides, there is another study which indicates that “behavioural change in human scurvy patients has a physiological rather than a solely psychological basis”[6].  And there is a suggested biological explanation. “Vitamin C is a cofactor in the biosynthesis of catecholamines, most notably in the conversion of dopamine to norepinephrine, which may explain the behavior and mood disorders associated with vitamin C deficiency”[7].  “Acutely hospitalized patients experience emotional distress for many reasons; therefore, it may seem unexpected that simple correction of their vitamin C deficiency could account for such rapid and dramatic improvements in psychological well-being. There are several reasons why this possibility merits serious consideration. First, the result is biologically plausible. Psychological dysfunction is known to occur in vitamin C deficiency, presumably because of the involvement of ascorbate in neuronal transmission and in brain neurotransmitter and fuel metabolism.”[8] 

20.   Vesalius’ reaction was normal in the view of many passengers getting sick, dying and being thrown overboard.

Did all the passengers start begging the crew not to throw their dead bodies overboard? Did Boucherus do it? Why did he then only report Vesalius doing it? Was it normal behaviour for a distressed 16th century aristocrat to beg lowly-born sailors?

21.   The only known symptoms of Vesalius are consistent with many other diseases.

I think the best way for someone to debunk the scurvy theory is to make a list of diseases that could have killed Vesalius. It appears that the authors do not consider it too great a challenge. But these diseases have to be compatible with the circumstances and the authors will have to do considerably better than the suggestion of food poisoning.

22.   Vesalius died from exhaustion combined by illness. 

All sources agree that Vesalius died from an illness. He had gone through an ordeal, he was probably malnourished and dehydrated to some extent but there is no evidence of exhaustion. He was sick, not tired. He was a passenger on a ship, not a galley slave. The crew, who worked around the clock, were fine. The only exhaustion was that of his reserves of Vitamin C.

23.   In order to have a definite diagnosis, it will be important to locate the grave of Andreas Vesalius.

Amen. I have one more reason to wish it than most of the many people who wish Theo and Pascale good luck in the search for the grave. I expect to be vindicated. And I hope that maybe my work will contribute in the beyond doubt identification of Vesalius’ remains.

[1] Voyages and Travels in the Levant in the Years 1749, 50, 51, 52, London 1766, p. 147.
[2] Medicina Nautica: an Essay on the Diseases of Seamen, Volume III, London 1803, p. 387.
[3] De magnis Hippocratis Lienibus Libellus, Antwerp 1564, pp. 26a – 31b.
[4] A voyage round the world in the years MDCCXL, I, II, III, IV, 5th edition,
London 1749, p. 101.
[5] Robert A. Kinsman and James Hood, Some behavioral effects of ascorbic acid deficiency, The American
Journal of Clinical Nutrition, April 1971.
[6] Fiona E. Harrison, Behavioural and neurochemical effects of scurvy in gulo knockout mice, Journal for
Maritime Research, Volume 15, Issue 1, 2013.
[7] Olivier Fain, Musculoskeletal manifestations of scurvy, Joint Bone Spine 72, 2005.
[8] Wang et al, Effects of vitamin C and vitamin D administration on mood and distress in acutely hospitalized patients, the American Journal of Clinical Nutrition, 2013.

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