Rembrandt’s hand – in praise of God or Man?

Monday, June 25th, 2012 | MICHAEL COP | No Comments

Terence Doyle writes…

‘The Anatomy Lesson of Dr Nicholaas Tulp’ is an enigmatic painting. Firstly, Tulp was not the praelector’s real name and secondly, whatever else this is, it is not a usual anatomy lesson. Many interpretations of it have been given but none, as far as I know, have suggested the one which I am about to offer.

At the age of 26, Rembrandt was commissioned by the Amsterdam Guild of Surgeons to paint the picture in 1632. It shows Dr Tulp lifting the flexor digitorum superficialis muscle of the cadaver forearm and at the same time flexing the fingers of his left hand to demonstrate the effect of contracting this muscle. The flexor digitorum profundus muscle can be seen deep to Tulp’s forceps and importantly the insertion arrangement of the two tendons at the fingers is shown in superb detail. Inspection shows how the superficialis tendon inserts on the middle phalanx after splitting and passing on either side of the profundus tendon, which carries on to insert into the distal phalanx. But why is the painting paradoxical?

Nicholaas Tulp was born in 1593 Claes Pieter or Nicholaus Petrus, son of Pieter Dirks, a prosperous Amsterdam merchant. As part of a successful medical career, Tulp became Praelector in anatomy in 1628 to the Surgeons Guild in Amsterdam. He seems to have adopted the name Tulp (tulip in Dutch) early on for reasons that are not clear. The individuals in the painting, including the cadaver, are all known. The spectators are Amsterdam surgeons – none medically qualified – who are named on the list held by the one to Tulp’s right. The surgeon standing upright at the back originally wore a hat, the outline of which can just be made out, and the figure to the far left of the group was added later by a hand inferior to that of Rembrandt (note the different skin tones). The inner three are looking at Tulp’s hand but the outer four are not.

Members of the Surgeon’s Guild, in England as well as in Holland, were required to attend anatomy demonstrations as part of their continuing education. However, this is not a usual anatomy demonstration for several reasons. Dissection always followed a set pattern of the abdomen being examined first since its organs putrefied rapidly, then the chest and brain for the same reason, and finally the limbs. In the painting, only the forearm has been dissected – with the fingers shown in great detail and the flexor muscles in just enough detail to show their function. The dissected hand is noticeably larger, and the left arm longer, than the right. Finally, the only spectators are surgeons (and only half of them are watching the ‘lesson’), whereas there would commonly be other prominent persons who came to witness the spectacle for a fee. We might therefore suppose that this painting is largely to do with surgeons and the hand.

The idea of Man as microcosm was common in the Early Modern Period and thus the study of anatomy was a study of the works of the Almighty – cogitio sui and cogitio Dei. Moreover, the hand was emblematic of such miraculous works. This was a view of Aristotle who considers the hand the physical counterpart of the human psyche, being an instrument for using other instruments. Galen, in book XVII of On the use of the parts, says of the tendons: ‘their insertions in the bones and their relations with each other are amazing and indescribable.’

The anatomist John Banester says of the hand: ‘no member more declareth the unspeakable power of almighty God in the creating of man.’ (John Banester. The historie of man, sucked from the sappe of the most approued anathomistes, London, 1578, p. 61).

Helkiah Crooke, in his ‘μικροκοσμογραφία [mikrokosmographia]: a description of the body of man . . . collected and translated out of all the best authors of anatomy especially out of Gasper Bauhinus and Andreas Laurentius’, London, 1615, considers that the hand ‘may justly be compared to the soule . . . By the helpe of the hand laws are written, temples built for the seruice of the Maker’ (p. 729). The hand is ‘the most Noble and prefect organ of the body;’ and Laurentius, whom he refers to as ‘one of the outstanding Doctors and teachers of divine wisdom’ noted the wonderful artistry ‘with which nature perforated the tendons of flexor superficialis in order to provide the passage for the profundus tendons’ (p. 730). This encomium on the hand comes from the chapter de praestantia manus in Laurentius’s Historia anatomica humani corporis, Frankfurt, 1599, pp. 61-3.

I think the painting is an allegory on the word ‘surgeon’. In this period, the word was often written (even in Dutch) something like ‘cheirurgeon’ which derives from the Greek χείρ (hand) ἔργον (work). Since the painting is so clearly about surgeons and hand function (as Tulp is demonstrating), the connection seems to me compelling. Perhaps it also suggests that those individuals are metaphorically closer to God by association – they did pay for the painting after all. An interesting area for future research might be the use of the hand as emblem of the Divine in Early Modern period.

What killed Charles II?

Sunday, June 17th, 2012 | Peter Anstey | No Comments

Terence Doyle writes…

Charles II, at the age of 54, laid down his earthly crown for an immortal one at noon on Friday February 6th 1685. His last illness is surely the best documented case history in the seventeenth century. There were multiple eyewitness accounts. The official version was penned by the Chief Royal Physician Sir Charles Scarburgh and later transcribed in The Last Days of Charles II by Raymond Crawfurd, (Clarendon Press, Oxford, 1909). It makes disturbing reading.

Charles was an apparently healthy man, reputed to have had thirteen mistresses and fifteen illegitimate children. On Monday morning, February 2nd 1685, while at his ablutions, he suffered a seizure with convulsions and temporary slurring of speech. Two physicians were on hand and one, Edmund King, withdrew 16 ounces of blood (450ml) from the king’s right arm, apparently with immediate relief. Six more physicians soon arrived and removed another 8 ounces with cupping glasses applied to deep scarifications in the shoulders. He was then given both an emetic and a purgative to empty his stomach and bowels. This was followed by two enemas and further purgatives. Then, according to the official account, Praeterea ut nullum lapidem immotum reliquerent (to leave no stone unturned) blistering agents were applied all over his head, after his hair had been shaved.

It was then decided to relieve the pressure of the humours on the brain by inducing sneezing, with a powder of white hellebore roots and later Sal Ammoniac applied to the nostrils. So as to keep his bowels active at night, more laxatives were given two hourly. At the same time, to counteract the scalding of his urine, from the Cantharides in the blistering drugs, a soothing emulsion of barley with liquorice was given. Et ne quid intentum relinqueretur (so as to leave nothing untried), plasters containing Spurge and Burgundy Pitch were applied to the soles of his feet.

On Tuesday he was bled ten ounces from the jugular veins. On Wednesday he was given further laxatives but that night he became so ill that his doctors prescribed Spirit of Human Skull (40 drops). This was commonly used in convulsive disorders and thought to act through the power of suggestion, since the skull had to be from someone who had died violently. On Thursday the King’s ministers were asking just what was wrong with him – a piece of intelligence the doctors themselves would have been happy to have. It was then suggested that he was suffering from intermittent fever and so was given syrup of Chinchona (Jesuit’s) bark three hourly, according to a prescription signed by 14 doctors.

On the morning of Friday 6th he was bled again and given an extract of a very large number of herbs, powdered oyster shells and Goa stone. This latter was a concretion (bezoar) formed in the stomach of an East Indian goat and was believed to have mystical ability to counteract poisons and strengthen the vital powers.  By mid-morning he was severely short of breath compelling him to sit upright. By ten he was comatose, and at noon he died.

On Saturday 7th an autopsy was performed, presumably because the illness was unexplained. The results of the autopsy are well documented.

 In Cerebri Cortice Venae et Arteriae supra modum repletae. (The veins and arteries on the brain surface were abnormally full).

Cerebri tum ventriculi omnes serosa quadam materia inundati, tum ipsa substantia consimili humore haud leviter imbuta. (The cerebral ventricles were filled with a kind of bloody material and the brain substance contained a similar humour).

The lungs were Sanguine referta (congested with blood). The heart and abdominal organs were unremarkable.

Crawfurd confidently sums this up with: ‘From these accounts one may assert with considerable confidence that his death was due to chronic granular kidney (a form of Bright’s disease) with uraemic convulsions, ‘He was a large eater and mainly of albuminous food. Alcohol he had taken freely, at times to gross excess: he had been the slave of sexual passion’ (p. 16).

This is manifestly incorrect. At autopsy the kidneys were normal and so Bright’s disease (chronic glomerulonephritis) is most unlikely. Overindulgence in eating, alcohol and sex, although lamentable, rarely results in death. The clinical history sounds like cerebral bleeding, probably subarachnoid. This is due to leakage from an arterial aneurysm, minor at first but irritating to the coverings of the brain. Charles remained conscious and there was no limb weakness. The first subarachnoid haemorrhage has an increased likelihood of a second more catastrophic bleed after a few days, this time into the brain substance. This pattern fits Charles’ clinical course. Just before he died he became severely short of breath. This is likely to have been caused by neurogenic pulmonary oedema, sometimes associated with intracerebral events. Finally, the autopsy findings state that the cerebral ventricles were filled with bloody fluid and a similar kind of material in the brain substance. This is just what would be expected in subarachnoid and secondary intracerebral bleeding.

Who performed the autopsy is not recorded. However, since Richard Lower had much the most experience of intracranial examination after working with Thomas Willis, he must have been involved.

Despite theoretical advances in medical science at this time, practical treatment as shown in the King’s management was still rooted in humoural theory. Towards the end of his illness Charles made his famous remark about being an unconscionable time a-dying, which sounds more like a prayer for deliverance than an apology.


Thomas Sydenham’s Tractacus de Podagra

Sunday, May 13th, 2012 | Peter Anstey | No Comments

Terry Doyle writes …

If Thomas Sydenham (1624–1689) were transported to a modern lecture hall to hear a chemical pathologist explaining how gout is caused by the bodies of some individuals being unable to metabolise and excrete uric acid, which is then deposited in the peripheral joints, he would probably mutter to himself, ‘that is just as I thought’. Reading his Tractacus de Podagra of 1683 in Latin is interesting on at least two counts. The first is for the excellent clinical description of gout and the second is the frequent use of Greek text. As Peter Anstey most helpfully pointed out to me, Sydenham wrote only in English and had all his work translated into Latin, and his Tractatus was probably translated by Gilbert Havers or John Mapletoft.

Coming to De podagra as a neophyte in this area, a working doctor is immediately impressed that here one is reading the product of practical experience – obviously Sydenham is very familiar with the various presentations of gout, of which he was, famously, a sufferer himself. He describes the systemic and prodromal symptoms leading up to a full-blown attack of the disease, noting that although it most commonly affects middle aged men, it rarely affects women and then after menopause. He notes that some cases seem to have a hereditary basis and these individuals may be more slender and younger than the stereotypical obese over-imbiber of port wine. Some observations, seemingly inconsequential to the casual reader, are typical of the notes of a working doctor – such as his reference to the desquamation of the skin over a gouty tophus and the fact that although the initial attack affects one joint, later attacks are polyarticular and febrile. The work is sprinkled with such insightful observations.

Sydenham has been frequently referred to as the ‘English Hippocrates’ (see Peter Anstey, ‘The Creation of the English Hippocrates’, Medical History, 2011, 55: 457-78). One justification for this might be that he discusses the disease in terms of the Hippocratic doctrine of humours. If one were to substitute the words ‘uric acid’ for ‘excess of humour’ in De podagra (Sydenham freely admits he has no idea of the nature of this humour) one would have a fair description of the pathophysiology of gout. He says that the body of the sufferer is unable to ‘cook’, ‘separate’ and ‘evacuate’ whatever humour it is, and the products are deposited in the peripheral joints – which is essentially what happens. Secondly, Sydenham follows Hippocrates’ belief in the value of careful observation of symptoms. One of Hippocrates’ aphorisms is that if one listens to patients long enough, they will tell you the diagnosis. Thirdly, both believe that if the doctor can do no good, at least no harm should be done. Thus Sydenham suggests avoiding bleeding and purging, since in his experience they are not only useless but harmful. On the contrary, he found that drinking liberally of non-spirituous fluids (to flush out the renal stones) and partaking of mild sudorifics such as Sarsaparilla are at least helpful to the sufferers.

The other feature of interest in the Latin text of 1683 is the frequent use of Greek words in original script – at total of 37 words or phrases in 130 pages. On the first page he describes gout as ‘naturam δυσνοητον’ meaning ‘difficult to understand’. Most of the words are fairly straightforward like απεψια, αταξια, μιασματα, ανωμαλια. At one point he coyly says that flatus may be evacuated ‘sive ανω sive κατω’ (either upwards or downwards). Some words seem like new coinages, such as γαλατοποσια (a milk drinker) and ποδαγιωντων (of gout sufferers) but they appear in Liddell and Scott. The word ‘podagra’ is derived from the Greek for ‘foot trap’, and is of ancient usage in English. The OED notes that John of Trevisa used it in his De proprietaribus rerum of 1398.

Greek words and text interspersed with Latin in medical books was not new. The first textbook on anatomy published in England, David Edwards’ Introduction to Anatomy of 1532 (facsimile edition edited and translated by C.D. O’Malley and K.F. Russell, Stanford UP, 1961), uses them freely. Edwards was Reader in Greek at Corpus Christi College Oxford in 1521 in addition to studying medicine. Sydenham would have studied Greek as part of his undergraduate course in medicine and his friend John Locke taught Greek for a time. What was the reason for the insertion of Greek words in to Sydenham’s Latin text? None appear to clarify the argument. They seem rather in the nature of literary flourishes, particularly when he refers to Lucian’s play Τραγοποδαγρα (The Gout Tragedy). He may be merely using the professional argot of his medical contemporaries, who mostly had a similar educational background. Modern doctors seem to use baffling acronyms for a similar end.

Three questions remain to be answered. (1) To what extent did Sydenham work in the reference frame of the Hippocratic doctrine of humours? (2) To what extent did 17th century doctors’ knowledge of Greek contribute to medical nomenclature? (3) What was Sydenham’s relationship with Thomas Short to whom Tractacus de Podagra was dedicated? Short took over Richard Lower’s lucrative practice when the Lower fell from Court favour because of his Whig politics. I look forward to hearing from readers who might be able to help with these questions.