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Written by: Pavlos Plessas

Published: May 17, 2016

Text from the presentation at the 2014 Vesalius Continuum Meeting in Zakyhnthos, Greece by Pavlos Plessas.

Continued from: Powerful indications that Vesalius died from scurvy (1)

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Metellus and Solenander agree on most of the details of the story, to the point that it appears the initial source of their information was the same person, however, their versions are not identical. Metellus claims to have received his information from Georgius Boucherus in person, in the presence of a reliable witness, while we do not know how many times the story was recounted before reaching Solenander. Hence, while Solenander provides some valuable information, it is Metellus’ version, notwithstanding his conjectures, that should be considered more faithful (8).

It is very clear from both versions that, some weeks into the journey, a disease broke out on board the ship. Also, more clear in Metellus than in Solenander, that Vesalius was a victim of the same disease, which was somehow connected to food and water shortages..

(Based on the above) It can be easily concluded that the mysterious outbreak does not appear to have been due to contagion on board the ship. Neither the crew was affected nor Boucherus developed symptoms, either during the voyage or in the following months, in spite of his close proximity with the patients for at least forty days. Consequently, the disease was the result of either a pathogenic factor the pilgrims came in contact with or of some nutrient deficiency.

Contact with a pathogenic factor should have happened before boarding the ship, with the possible exception of the pilgrims consuming contaminated food that was not available to the crew. That way they could have fallen ill with typhoid fever, which has a variable incubation period of up to 30 days. However, complications and death from typhoid usually occur in the third week of the illness, which would have been near the end of the journey. Vesalius would simply not have had the time to get worried, fall ill, develop complications and die by the time they reached land. His sudden collapse and death does not fit in well with typhoid either.

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Looking for pathogenic factors on land we can distinguish between vector borne diseases and poisoning. It is, however, inconceivable that the victims of some 16th century poison would have shown no symptoms for weeks after receiving a lethal dose. Therefore, only vector born diseases need be considered and from those only the ones that are very deadly and present in the region. None of these though agree with what Metellus let us know about the disease.

When considering the various nutritional deficiencies we only need to deal with those that could have led to multiple deaths within six weeks from the onset of obvious physical symptoms, and could conceivably have appeared under the prevailing conditions of the journey and the socioeconomic and cultural traits of the region. As such, only scurvy appears to fulfil the criteria. Many may think that even scurvy is not a good candidate since a six week sailing is not thought sufficient for its appearance.

In fact, very often scurvy did not take long to appear or cause deaths. According to the naval physician Thomas Trotter it was common for an 18th century British warship of the Channel Fleet to lose up to a dozen seamen to scurvy and have another fifty hospitalised during a cruise of just eight weeks (9). A scurvy patient on a ship rarely survived for seven weeks and many died much earlier (10).

Also, it has to be pointed out that Vesalius’ journey did not last only weeks; he left Venice sometime before the 24th of May (11) and died in Zakynthos in the middle of October, a minimum of five months. More than two of these he spent sailing and the remainder in semi-desert or desert conditions. The Holy Land in Vesalius’ time was arid and mostly barren, especially in the high summer. Many pilgrims, shocked by what they saw, believed the area had been cursed by God  (12). No vegetables grew at that time of year and only some grapes, grown by Christians, and figs, growing wild, could have been ripe. Both fruit contain very little Vitamin C (13).

Article continued here: Powerful indications that Vesalius died from scurvy (3)

Sources and author's comments:
8. There are additional reasons for this. In Solenander’s version there are efforts to explain certain aspects of the story, which may have been nothing but an intermediate informant’s speculation passed on as reliable information. An example of this is that, according to Solenander, Boucherus met Vesalius and the other pilgrims in Venice, and travelled with them to Cyprus where they separated. He went to Egypt while they continued to Jerusalem. On his return journey he travelled again via Cyprus and by coincidence met the same companions on the same ship. All this is possible but unlikely, especially if he meant that the ship waited for the pilgrims for three months. There is even the suspicion that at least one part of the original story was intentionally “corrected”: Metellus says that Vesalius collapsed and died soon after disembarking, while Solenander says he died on board the anchored ship. Conventional wisdom dictates that a very sick man does not disembark and walk on the shore of Zakynthos but expires on board his ship. This is not always true but the temptation to perform a little cosmetic surgery on the story is understandable.
9. Medicina Nautica: an Essay on the Diseases of Seamen, Volume III, London 1803, p. 387.
10. James Lind, A Treatise on the Scurvy, London 1772, p. 281.
11. This is the publication date of the Examen, in the preface of which Francesco dei Franceschi recalls Vesalius’ visit to Venice.
12. Felix Faber’s description is typical: 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.
13. Figs contain about 2 mg per 100 g; grapes 3.2 mg. Data from the United States Department of Agriculture. A man whose body stores of Vitamin C are very low will need to eat 10 – 12 figs or more than 60 grapes every day just to remain above the threshold of scurvy.

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Written by: Pavlos Plessas

Published: May 16, 2016

Text from the presentation at the 2014 Vesalius Continuum Meeting in Zakyhnthos, Greece by Pavlos Plessas.

This article appeared originally on the blog of Fr. Panagiotis Capodistrias, a Zakynthian priest and poet, and a former schoolmate of Pavlos Plessas on September, 2014. Published here with permission from the author

Pavlos Plessas

 
The circumstances of Andreas Vesalius’ death in Zakynthos in 1564 may have been described in one of two differing accounts, originally written by three different men between the years 1565 and 1573, in five different texts. No additional information from people who may have been in possession of some facts is known to have survived.

In two of those texts the writer Petrus Bizarus claims that a travelling goldsmith found the great anatomist abandoned in a miserable hut on a deserted beach, dying from an unspecified illness (1). The unnamed goldsmith, in spite of strong opposition from the locals, buried him with his own hands in a plot of land he purchased for that purpose.

The veracity of Bizarus’ account appears doubtful due to its pervasive vagueness and the improbability of such treatment of an important nobleman by both, the Venetian authorities of Zakynthos and his own companions. More importantly it is incompatible with the testimonies of Christoph Fürer von Haimendorf (2)  and Giovanni Zuallardo (3) , who saw Vesalius’ tomb at the Franciscan monastery of Santa Maria delle Grazie, in 1565 and 1586 respectively. Their testimonies are also supported by that of Filippo Pigafetta (4). From their descriptions it is obvious that Vesalius was buried with some decorum and his grave was not dug simply to prevent the desecration of the body by wild animals.

The rival account is given in two letters of Johannes Metellus (5) , written in 1565, and another by Reinerus Solenander  a year later. Two more of Vesalius’ contemporaries, Carolus Clusius and Henricus Pantaleon provided shortened versions of this account that do not offer additional information and, hence, will not be discussed further. According to Metellus and Solenander Vesalius’ tomb was paid for by a fellow passenger, a Georgius Boucherus of Nuremberg, returning from Egypt. This account is not only compatible with the testimonies of those who saw Vesalius’ tomb but its credibility is enhanced by Metellus’ mention of a gravestone, put up by Boucherus, and Solenander’s statement that Vesalius was buried “next to a chapel or shrine close to the port of Zakynthos”. Santa Maria delle Grazie was the only Western church near the port at the time (7). 

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In a rather unexpected way this account’s credibility is further strengthened by the astonishing events it describes. For if someone is to present a fabricated account it is natural to try and make it as believable as possible. Even if the aim is to impress or to shock, the disturbing inventions have to have plausible and uncomplicated explanations. Contrary to this we are told of a ship that was unable to reach land for forty days, of severe food and water shortages, the consequent outbreak of an illness that caused many deaths but strangely affected only the pilgrims, Vesalius becoming depressed and anxious – which in the belief of Metellus contributed to his illness – his pleading to the crew to not bury him at sea, and finally his death as soon as they reached land – a very sudden collapse by the city gate according to Metellus. It will be shown that this sequence of extraordinary events has a reasonable, quite likely even, and singular explanation.

Article continued here: Powerful indications that Vesalius died from scurvy (2)

Sources and author's comments:
1. Historia di Pietro Bizari della guerra fatta in Ungheria dall'invictissimo imperatore de'christiani contra quello de'Turchi, Lyons, 1568, p. 179; also in his Pannonicum bellum, Basel, 1573, p. 284.  
2. Itinerarium Aegypti, Arabiae, Palaestinae, Syriae, aliarumque Regionum Orientalium, Nuremberg, 1621, p.2  
3. Il devotissimo Viaggio Di Gierusalemme, Rome, 1595, pp. 85 – 86.  
4. Theatro del Mondo di A. Ortelio: da lui poco inanzi la sua morte riveduto, e di tavole nuove et commenti adorno, et arricchito, con la vita dell' autore. Traslato in lingua Toscana dal Sigr F. Pigafetta, 1608/1612, background information to Map 217. Pigafetta, commenting almost two decades after his visit to Zakynthos in July 1586, mistakenly named the burial place of Vesalius as the monastery of St Francis. However, he leaves no doubt with regards to which monastery he actually meant by corroborating Zuallardo’s story of the inscription’s looting by the Turks in 1571. There was indeed a St Francis monastery in Zakynthos. It was, however, inside the castle and, hence, it was never looted by the Turks. Santa Maria delle Grazie on the other hand was in the area that is known to have been looted. I am grateful to Marcel van den Broecke for sending me photographs of the original text kept in the Koninklijke Bibliotheek in Hague.  
5. Metellus’ letter to Georgius Cassander was published in Petrus Bertius’ Illustrium & clarorum Virorum EPISTOLAE SELECTIORES, Superiore saeculo scriptae vel a Belgis, vel ad Belgas, Leyden 1617, pp. 372 – 373. His short letter to Arnoldus Birckmannus is unpublished though an English translation is in Charles Donald O'Malley’s Andreas Vesalius of Brussels, 1514-1564. A photocopy was kindly provided by the Cushing/Whitney Medical Historical Library of Yale University and a transcript made by Maurits Biesbrouck.
6. Maurits Biesbrouck, Theodoor Goddeeris and Omer Steeno, The Last Months of Andreas Vesalius: a Coda, Vesalius – Acta Internationalia Historiae Medicinae, Vol. XVIII, No 2, December 2012, pp. 70 – 71, from Thomas Theodor Crusius’ Vergnügung müssiger Stunden,oder allerhand nutzliche zur heutigen galanten Gelehrsamkeit dienende Anmerckungen of 1722. 
7. The monastery of St Elias was on the hill high above the port and St Franciscus even higher, inside the castle. St Mark was built later, in the 17th century.

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Published: May 13, 2016

This article is part of the series "A Moment in History" where we honor those who have contributed to the growth of medical knowledge in the areas of anatomy, medicine, surgery, and medical research.

William Harvey

William Harvey (1578 - 1609) English physician, physiologist, and anatomist. He was born in Folklestone, where his  father was the mayor.

Harvey studied at the King’s College in Canterbury, after which he entered Cambridge. He later traveled through France and Italy and continued his studies in Padua, where he graduated with an MD in 1602. He later returned to Cambridge to complete his Doctoral studies.

He became the Physician-In-Charge at St. Bartholomew’s Hospital.  It was at this time that he started a long process of scientific observation and logical reasoning that led him to postulate the circulation of the blood in his 1628 publication  "Excercitatio Anatomica de Motu Cordis et Sanguinis in Animalibus"  (Anatomical Exercises on the Movement of the Heart and the Blood in Animals).

Harvey’s publication caused incredible controversy, as his proposed theory went against Galen’s theories and the idea that blood passed through "invisible pores" from the right to the left atrium of the heart. His main problem was that he could not prove the presence of capillaries, which were not observed until Antoine van Leeuwenhoek invented the microscope in the late 1600's.

In his book Harvey states ''It is absolutely necessary to conclude that the blood in the animal body is impelled as in a circle and is in a state of ceaseless motion: that this is the act or function which the heart performs by means of the pulse, and that it is the sole and only end of the motion and contraction of the heart”. Even today there are many that use the term “circulatory system” without realizing that the meaning “as in a circle” coined by William Harvey is present in it.

Although the first to consider the term “circulation” was Michael Servetus (1511 – 1553), his ideas were not completely evolved. Had he completed his research and studies Servetus could have precluded Harvey, but he was considered a heretic and burnt at the stake. Thankfully, Harvey was not!  

Sources:
1. "William Harvey"Billimoria, A.  J Assoc Phys 60 (2012) 57
2.  “William Harvey” Foucar, HO. Can Med Assoc J 1951; 64(5): 452–453.
3. “William Harvey” McKecnie, EDJ, Robertson, C.  Resuscitation 55 (2002) 133-136
4. “William Harvey, an Aristotelian anatomist” Fara, P. Endeavour 21:2 (2007) 43–44
5. “The life and work of William Harvey” Keele, KD Endeavour 2:3 (1978) 104–107
Original image in the Public Domain. Courtesy of the National Library of Medicine

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Published: May 12, 2016

UPDATED: The suffix [-(o)pexy] means "fixation" or "surgical fixation". This surgical fixation or repositioning is performed on an organ or portion of an organ that has been displaced or detached by weakness of the surrounding tissues, trauma, or other means. The fixation can be attained by the use of sutures, surgical staples, bone tacks, mesh, etc. or a combination of these devices.

Some applications of this suffix are:

• Hemorrhoidopexy: Surgical repositioning of hemorrhoids.
• Nephropexy: Surgical repositioning and fixation of a kidney when the kidney "falls" or easily moves from its normal position.
• Hysteropexy: Surgical repositioning and fixation of the uterus. Uterine body displacement can lead to infertility.

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Published: May 11, 2016

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UPDATED: The term [Crux Cordis] is Latin and means "the cross of the heart". It is an anatomical landmark used in angiography. It is formed by the crossing of the atrioventricular sulcus and the conjunction of the posterior interventricular sulcus and the interatrial sulcus.

In the accompanying image the atrioventricular sulcus is colored blue, the posterior interventricular sulcus is red, and the interatrial sulcus is green.

The right coronary artery, posterolateral artery, and the circumflex artery are found in the atrioventricular sulcus. The posterior interventricular artery (PDA) is found in the posterior interventricular sulcus.

The AV node artery, which provides blood supply to the AV node (a component of the conduction system of the heart) usually arises from the PDA , the right coronary artery, or the posterolateral artery at the level of the crux cordis.

The interatrial sulcus is curved and hugs the inferior vena cava. It is known eponymically as Waterston's groove (David J. Waterston, British surgeon and anatomist 1910-1985) and also as Sondergaard's groove.

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Written by: Efrain A. Miranda, Ph.D.

Published: May 10, 2016

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Image modified from the original
(Singh and Ohri, 2006

The [triangle of Calot], also known as the “cystohepatic triangle” is a triangular region found within the lesser omentum connecting the duodenum, stomach, and liver. It is an area bound superiorly by the inferior surface of the liver, laterally by the cystic duct and the medial border of the gallbladder, and medially by the common hepatic duct.

The surgical importance of this area is for a cholecystectomy. It is within this area that the surgeon will usually find the cystic artery, a critical structure that needs to be ligated in this procedure.  I stress the term “usually” as the hepatobiliary tree is one of the areas in the human body that has the most anatomical variations. In fact, the anatomy in this region is considered to be “normal” only in 64% of the cases. The cystic artery may not be found in the triangle of Calot therefore careful dissection and identification of the structures is needed in every surgery.

The above description of the triangle of Calot is what some refer to as the “modern triangle of Calot”, as the original triangle described by Dr. Jean-Francois Calot (1861 – 1944) is different.

Calot’s original description of this triangle is: “Le triangle n’est pas exactement équilatéral, mais plutôt isocéle, les deux cotés supérieur et inférieur, représente par l’artére et le conduit cystique, étant seuls égaux, et un peu plus longs que la partie du canal hépatique qui entre dans la constitution du triangle’’ , which can be translated as: “ The triangle is not exactly equilateral, but rather an isosceles triangle. The superior and inferior sides, represented by the cystic artery and cystic duct, are equal and a little longer than the part of the hepatic duct, which enters into the formation of the triangle. (Abdalla, 2013).

In the accompanying image Calot’s original triangle is shown by horizontal blue lines while the modern version of the triangle of Calot is shown with vertical red lines.

Sources:
1. “Calot's triangle” Abdalla S, Pierre S, Ellis H. Clin Anat. 2013 May;26 (4):493-501
2. “Anatomic landmarks: their usefulness in safe laparoscopic cholecystectomy” Singh, K; Ohri, A. Surg Endosc (2006) 20: 1754–1758
3. “Surgical Anatomy” Deaver, J P. Blakiston's Son & Co. Philadelphia, 1901
4. "Tratado de Anatomia Humana" Testut et Latarjet 8th Ed. 1931 Salvat Editores, Spain
Image modified from the original (Singh and Ohri, 2006. Pastel sketch by Dr. E. Miranda