Rembrandt painted his celebrated Anatomy Lesson of Dr Nicolaas Tulp in Amsterdam in 1632, a time when anatomy itself was changing radically. Four years earlier, the Englishman William Harvey had described the circulation of the blood. Tulp’s fame as an anatomist was destined to be eclipsed by the work of the lens maker Anton van Leeuwenhoek, who was born in Delft that same year and whose microscope would make the invisible visible. Knowledge of anatomy as studied with the naked eye had progressed as far as it could and the structure of the dead body was known; the new field for study would be how the living body functioned.
The Anatomy Lesson offers a glimpse of certain medical and administrative aspects of death in 17th century Amsterdam. The city had just opened its own athenaeum (forerunner to the modern University of Amsterdam) to rival the one in Leiden, and Tulp’s lesson would show that Amsterdam was second to none in anatomy. An anatomy lesson was a public occasion, attended by city councillors, surgeons, physicians and other interested persons. It sometimes lasted several days, and so for obvious reasons was given in winter.
Ironically, the cadaver was that of a man from Leiden – Aris Kindt – who had been hanged in Amsterdam for repeated thefts of clothing. In the painting, Kindt’s pallid corpse occupies the centre of the canvas, but the viewer’s attention is drawn to Tulp. He wears the black physician’s hat and is lecturing, holding in his hand a pair of forceps; with them he lifts the muscles and tendons of the lower left arm. Seven senior members of the surgeons’ guild observe. A book on anatomy appears in the lower right-hand corner.
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ARTISTIC LICENCE
But what is depicted is not what actually took place. Anatomy lessons always began with the dissection of the internal organs, because those were the first to deteriorate – never with the arm. Rembrandt has left the body intact to make the picture less gruesome and to focus attention on Tulp. Also, there is probably a symbolic relationship between the book on anatomy and Tulp’s dissection.
A century before, the Flemish anatomist Andreas Vesalius had laid the foundations of modern anatomy with his research. Medical history is said to begin with his atlas, De humanis corporis fabrica (‘On the Structure of the Human Body’). Vesalius’s text and woodcuts opened up a new world. For 13 centuries, the writing of the Greek anatomist Galen had been followed blindly, including the dictum that the body of a deceased person could not be violated for scientific purposes. As the physician to gladiators in Pergamum, Galen must have been in a position to observe many anatomical details, internal and external. But he derived his knowledge from pigs and apes, and his interpretations of what he found were based on untested theories. His authority, and then that of the medieval church, placed anatomy on the wrong track and kept it there until the time of Vesalius.
In all the editions of his work, Vesalius appears in a woodcut that shows him holding the dissected hand and arm of a cadaver. The hand was the first part of the body that Vesalius studied; the hand was also the surgeon’s first instrument. And so Tulp is painted as Amsterdam’s Vesalius, and it may be the latter’s book that appears in the lower right-hand corner. In any event, Tulp’s teacher in Leiden had studied with Vesalius in Padua, and admired him. Tulp, in his public lesson, carries on the tradition.
Tulp was both mayor and anatomist. Like Rembrandt, he was a well-known figure in Amsterdam’s canal district. He wrote about a number of new discoveries, sang the praises of the newly introduced tea leaf as a universal remedy, and compiled the first pharmacopoeia, a guide for pharmacists in preparing medicines. Tulp had a busy practice, which he attended to by means of his horse-drawn coach and in his consulting room on the lower floor of a house on the Keizersgracht. He spent half a century on the Amsterdam city council, and in addition to all these activities he was an astute physician whose professional accounts of unusual and sometimes bizarre cases, written in Latin, gave him a great reputation. He was no Leeuwenhoek and did not advance his profession, but was still a shrewd and useful observer who opened the eyes of many contemporaries. He would be forgotten if Rembrandt had not immortalised him.
Life did not turn out that well for the original Vesalius. The publication of his masterpiece on human anatomy, at the age of 28, made him the founder of a new science, but not without a struggle. His critics, faithful to the old authority of Galen, did not believe the evidence of their eyes, and Vesalius had to endure harsh condemnation of his work and methods. Embittered, he gave up scientific research, burnt his notes, and became the personal physician to the Spanish monarchs Charles V and Philip II. At the court he once treated a nobleman with a mysterious ailment; when the patient died, he asked for permission to perform an autopsy. It was rumoured that Vesalius opened the chest cavity and found the heart still beating. On the strength of this, the Spanish Inquisition charged him with sinning against God and man, and would have had him hanged if the King had not intervened. As penance, Vesalius was compelled to make a pilgrimage to Jerusalem. On the return voyage he was shipwrecked, and died in 1564 on Zakinthos, an island off the coast of the Peloponnese. The story of the beating heart may be apocryphal, but it is an intriguing one – at the boundary between life and death, the founder of the science of anatomy makes a mistake.
HANDS-ON EXPERIENCE
As medical science progressed, the public anatomy lesson was discontinued as physicians sought to treat their patients by investigating the body for themselves. In the 17th century, physicians were well read but without practical experience, content to observe their patients before alleviating suffering. By the 18th century, the emphasis switched to practical experience; the control of epidemics, public health and the diagnosis of the disease while the patient was still alive. Nevertheless, anatomical knowledge remained the basis for such common procedures as setting bones, bleeding, splinting and bandaging. That is why the British surgeons’ guilds were given the monopoly on autopsies of hanged criminals – although the autopsies were of scant practical benefit for things like amputations or bladder stones.
Operations were performed by filthy surgeons on fully conscious patients lying on wooden tables and bandaged with dirty linen. The principles of infection of wounds were unknown, often with fatal results. The medical student Charles Darwin, after witnessing two operations in Edinburgh, changed his mind about becoming a doctor. In the early 1800s, hospitals were places for the indigent sick to die, inns of death for the wounded, the unwell, and women in childbirth. Although there was some medical experimentation with live patients, hospital managements and the authorities permitted this on the deceased only in exceptional cases.
In the 18th century in Amsterdam, physicians and professors began to ask the municipal authorities for permission to perform at least four autopsies annually on persons who died in a hospital. The hospital regents consistently opposed this. The state argued that the indigent had profited from their hospital stay and could settle their account, after their death, with an anatomy lesson, but the hospital administrators preferred payment in cash.
Not until after 1800, when improved medical education, research and nursing led to the development of the modern clinic, did anatomy take its rightful place in the science of pathology. Speculations about the structure and functioning of the human body gave way to actual observations and descriptions of disorders at the bedside, and to the search for their physical causes on the operating table. One of the founders of the Vienna medical school, pathologist-anatomist Karl von Rokitansky, performed more than 60 000 autopsies in the course of his career.
British anatomists of the 18th century, like those elsewhere, had to be satisfied with the cadavers of the hanged, but even for this they needed the permission of the authorities. Though hangings were numerous, the many anatomy schools and the surgeons’ guilds had an inadequate supply of bodies; the condemned, the executioners and their assistants all had to be bribed in order to obtain cadavers.
A simpler method of acquiring study material for the anatomists was body snatching. Paupers were usually buried in communal graves, and their corpses could easily be taken from their coffins. And the surgeons’ guilds paid well. London had entire gangs of so-called resurrectionists; at fixed rates, they stole bodies from mortuaries. The famous physicians John and William Hunter were involved in such activities. In 1783, John Hunter bribed an undertaker £500 to obtain the corpse of an Irish giant who had made his name as a circus attraction in London. Many anatomists were after the body, if only to add it to their collections of curiosities, but it ended up in Hunter’s hands, in spite of the man’s wish to be buried at sea. The unfortunate Irishman’s skeleton is still on display in the Hunterian Museum at the Royal College of Surgeons in London.
BODIES IN THE BIN
Public disgust increased as the number of thefts rose. In 1832, a new anatomical institute in Aberdeen was set on fire after the discovery that its staff was treating corpses like garbage. When it came out that important hospitals were giving their indigent patients mock burials and then retrieving bodies at night for use in the dissecting room, the House of Commons finally appointed a commission of inquiry. Physicians of high repute protested that medical science could not advance without anatomical knowledge, since the body’s functions were based on its structure. Anatomical study, they said, benefited the living, and this worthy end justified less than fastidious means.
The initiator of this position was Jeremy Bentham, the philosopher of social benefit, who believed that by reforms of the law, society could bring the greatest possible good to the greatest number of people. A typical man of the Enlightenment, he had no doubts about the scientific necessity of anatomy, and by the early age of 21 had already bequeathed his body to science. Bentham argued that the needy in hospitals, because they could not pay for their care, had tacitly consented to autopsy in the event of death. In due course they would be given a Christian burial, he added – a considerable improvement over the current practice of doing it the other way around.
As the parliamentary commission went to work in 1828, an incident in Edinburgh greatly inflamed the debate. An Irishwoman without money or food, who had come to Edinburgh in search of a lost son and was begging in a bar, was taken home by one of the customers, a man named Burke. At a party there she was given food and drink, and later that night Burke murdered her. The crime was discovered the next day, and Burke confessed. It turned out that Burke and an accomplice named Hare had done away with 16 unfortunate wanderers after luring them from the streets and getting them drunk. The bodies had been delivered, at a high price per body, to the eminent surgeon and anatomist Robert Knox. On the strength of Hare’s confession, Burke was hanged in public, in the presence of a cheering Scottish throng. As a further punishment, his corpse was consigned to the dissectors, and the judge stipulated that his skeleton be preserved as a reminder of the crime. So the dealer in cadavers himself became an anatomy lesson, which was attended the first day by 2000 students and the next day by 30 000 curious citizens of Edinburgh. Hare and Knox went free.
In 1832, after lengthy debate, Parliament adopted a law permitting hospital and poorhouse administrators, subject to certain legal controls, to make the corpses of indigent patients available to the dissecting room without the obligation of burial. The institutions thus saved on funeral expenses, and the dissectors got their corpses. The anatomy lesson now ceased to be a posthumous punishment and became instead a worthwhile – albeit compulsory – way for the dispossessed to express their thanks for services rendered.
While the last legislative touches were being put to the anatomy law, its spiritual father, Bentham, died. Friends and relatives were invited to an anatomy lesson in London, to be conducted by Bentham’s friend, the anatomist Southwood Smith, as the deceased had requested. Under the terms of Bentham’s will, his body was to be delivered to Smith, who would dissect it, mount and clothe the skeleton, and dry out the head. For 20 years, Bentham had owned the glass eyes that were to stare out from his desiccated skull. He considered his remains useful for dissection; his skeleton, on the other hand, if properly preserved, could be his monument – or, as he put it himself, his auto-icon.
Bentham had thought of the auto-icon as a lasting monument; had envisioned temples set in avenues of trees and filled with auto-icons of good people and bad – a sort of anatomical homily. He had many ideas about ways of preserving them, and even saw them as characters in historical tableaux. A rationalist, Bentham could conceive of how the dead might be of benefit to the living, and not only as solemn reminders of mortality. He wanted to be his own relic, visited by admirers, an example for others to follow. In addition, by bequeathing himself to an able and trustworthy anatomist, he escaped the collecting mania of surgeons and body snatchers. His example, however, was not followed; the new law provided for enough corpses from the poor. And time took its toll of his auto-icon, until its recent rehabilitation.
The pathologist-anatomists of today speak of autopsy as the final consultation. It is performed mainly for purposes of instruction to confirm a clinical diagnosis that may have been incomplete or inaccurate. It is not the importance but the methodology of the autopsy that has changed drastically.
Better diagnostic techniques, such as X-rays, tissue analysis and a multitude of laboratory tests, leave few questions unanswered. The deceased, usually elderly and succumbing after a long illness and a multiplicity of afflictions, does not generally provide any surprises. What is more often cause for astonishment is that such an emaciated and ravaged body contained life only a short while before. Pathological anatomists themselves usually show little interest in autopsies, a relatively primitive method today, preferring more subtle microscopic methods.
Dutch law says that people own their bodies and that without their permission, government authorities and others have virtually no right of disposal over them. The body of the deceased belongs to his or her heirs, to dispose of within the limitations imposed by the law and the wishes of the deceased. Thus the permission of relatives is required before an autopsy can be performed, and they frequently refuse. Courts can order dissection only in the event of unnatural death: a suspicion of medical error, an accident or an indictable offence. Not for the edification of the physician, but to detect a crime.
The current attitude toward autopsy derives from our way of looking at death. One used to die; now, one passes away. The former seemed a more active process. The seriously ill were aware of their impending death, prepared themselves for it, gathered their friends and relatives around them for a last farewell. If at all possible, one made one’s peace with God and man, closed one’s eyes, expelled the last breath, and died – stiffened – in one’s own bed, in one’s own house. One was laid out before being carried to the grave, there to await some form of eternal life as recompense for a too brief and often unhappy existence. Dying was also a lesson on how to live, a model of leave-taking and hope. In the cemeteries of many religious orders the headstones omit the date of birth and are engraved only with the date of death, when the new life begins.
Since Bentham’s day, if not before, such beliefs have largely disappeared. Dying no longer offers moral instruction; at best, it can serve a useful purpose in supplying organs or parts of them, ranging from the cornea to the heart, from the kidneys to the liver, for transplanting, giving some of those condemned to die a new lease of life.
No one can force the decision on us. Yet, as with the poor of London, there is an unspoken assumption that those who are about to die should show their gratitude for the care they received by making a gift of their usable parts, which otherwise would go to waste. There is no shortage of potential donors; it is necessary only to wait for a traffic accident or a stroke.
What is left after transplantation is mortal remains, which served their purpose for the patient and possibly for others. Increasingly today, the remains are cremated rather than buried. In the Netherlands, the practice of cremation is close to a century old, although at one time it aroused as much indignation as body snatching did, being considered a ‘heathen’ ritual. People opposed to religion campaigned for the right to cremate corpses and, because the law was unclear, the relatives of the deceased at the first Dutch cremation, in 1914, were taken to court. The relatives were acquitted and, subsequently, more cremations occurred. In the near future, cremation will be an environmental necessity. There have been changes in the way we regard death and the discarded body, and changes also in the anatomy lesson. It is constantly teaching us something new, but it is also teaching us what it always has – that death can hold a mirror up to life.
A. J. Dunning is professor of cardiology at the University of Amsterdam. This article is an edited abridgement from his book Extremes: Reflections on Human Behaviour published on 28 January by Secker & Warburg at £14.99 (hardback, not illustrated). It is available from Reed Book Services, PO Box 5, Rushden, Northants NN10 9YX (Tel: 0933 410511). c 1990 by A. J. Dunning. English-language translation from the Dutch by Johan Theron. c 1992 by Harcourt Brace Jovanovich, Inc.