Snapping scapholunate subluxation

LETTERS TO THE EDITOR The Anatomy Lesson of Dr. Nicolaas Tulp To the Editor: In his famous painting The Anatomy Lesson of Dr. Nicolaas Tulp (Light TR: Hands on stamps. J HAND SURG 7:20, 1982), Rembrandt committed an anatomic error. The flexor superficialis digitorum arises from the elbow laterally instead of medially (Fig. 1).1. 2 This was probably not an anatomic anomaly. Several explanations have been proposed to defend the great painter. 3 It has been suggested, for instance, that Rembrandt purposely misrepresented the origin of the flexors to give greater artistic unity to the painting. 4 Heckscher 5 suggests that Rembrandt misinterpreted a Vesalian woodcut and confused the anatomy of the right arm with that of the left. He further states " ... a seventeenth-century anatomy would never begin with the arm and hand. The dissected parts Rembrandt clearly superimposed on a cadaver drawing after nature .... "6 The Anatomy Lesson of Dr. Nicolaas Tulp thus stands, not as a lesson in anatomy, but rather as a tribute to the distinguished career of Dr. Tulp and to the glorious genius of Rembrandt. Joseph C. Cremone. Jr .. M.D. Department of Surgery Beth Israel Hospital Harvard Medical School 330 Brookline Ave. Boston. MA 02215

REFERENCES 1. Robinson V: The Don Quixote of psychiatry. New York, 1919, Historico-Medical Press, p 39 2. Spielmann MH: The iconography of Andreas Vesalius.

3. 4. 5.

6.

London, 1925, John Bale, Sons and Danielsson. Ltd., p 116 Goldwyn RM: Nicolaas Tulp (1593-1674). Med Hist 5:270, 1961 De Lint JG: Rembrandt, The Hague, 1933, 1. Philip Kruseman, p 24 Heckscher WS: Rembrandt's Anatomy Lesson of Dr. Nicolaas Tulp. New York, 1958, New York University Press, p 150 Heckscher WS: Rembrandt's Anatomy Lesson of Dr. Nicolaas Tulp. New York, 1958, New York University Press, p 66

To the Editor: The students' facial expressions in Rembrandt'sAnatomy Lesson of Dr. Nicolaas Tulp (Light TR: Hands on stamps. J HAND SURG 7: 20, 1982) exhibit great concern. This intensity is fully justified as the doctors observe that the flexor pronator muscles originate from the lateral epicondyle. This rare anomaly, which is artistic rather than anatomic, probably resulted from Rembrandt sketching a right forearm in his preliminary drawings and then not accurately reversing the details for the left side in his final painting. Roy A. Meals. M.D. Division of Orthopaedic Surgery UCLA Center for Health Sciences Los Angeles. CA 90024

Snapping scapholunate subluxation To the Editor: I read, with great interest, the paper "Snapping Scapholunate Subluxation" by Jackson and Protas (J

Fig. 1. Rembrandt's Anatomy Lesson of Dr. Nicolaas Tulp. 1632 (The Hague). Detail of extremity dissection with anatomic error. 530

THE JOURNAL OF HAND SURGERY

Vol. 7, No.5 September 1982

Letters to the editor

HAND SURG 6:590, 1981). I have to admit that most of the cases are difficult to diagnose on roentgenograms and that fluoroscopic examination is very helpful. Most of the cases are overlooked and as evidenced in the paper (Fig. 1, Normal A-P roentgenogram in Case 1, Fig. 3, Clenched fist view in Case 1 shows normal scapholunate interval), one can already diagnose the lesions. Usually the space between the scaphoid and lunate is a parallel one and not triangular in shape. Whenever a posteroanterior or clenched fist roentgenogram shows such a triangle-the base of which is the articular surface of the radius and the arms of which are the articular surfaces of the scaphoid and lunate-a scapholunate dissociation can be suspected. I believe that the clinical findings with the x-ray findings as presented in this paper are sufficient for the diagnosis, and I would hesitate to read Fig. 1 and Fig. 3 as normal x-ray findings. I would appreciate the authors' comments on the subject. Avner Karev, M.D. Hand Surgery Unit Rambam Medical Center Haifa , Israel

Reply To the Editor: We disagree with Dr. Karev's interpretation of the findings in Figs. 1 and 3. It is our opinion that Fig. 1 is completely normal. Fig. 3 shows a very common variant, with the scapholunate joint tilted so that it is no longer perpendicular to the x-ray plate. We have seen this appearance on numerous studies, and none of our radiologists consider it abnormal. The triangular configuration of the entire scapholunate joint described by Dr. Karev would be diagnostic of scapholunate subluxation. Such a finding is well demonstrated in Figs. 1 and 3 of Howard et al. l Their Fig. 5 has the appearance of our Fig. 3 and is described as showing normal scapholunate relationships.

531

The findings at fluoroscopy were striking and led to our recommending surgery for these patients. We would not have done so on the basis of these plain x-ray studies, even with the clinical findings suggesting a scapholunate abnormality. Wm . Thomas Jackson , M.D . 207 Clinical Sciences Bldg . University of Texas Medical Branch Galveston, TX 77550 and Jacob M. Protas, M.D. Aspen Valley Hospital Aspen, CO 81611

REFERENCE I . Howard FM, Fahey T, Wojcik E: Rotatory subluxation of the navicular. Clin Orthop 104: 134-9, 1974

To the Editor: I would like to bring to the attention of the readers of THE JOURNAL OF HAND SURGERY an article by Prystowsky et al. in the New England Journal of Medicine, September 16, 1976, entitled "Invasive aspergillosis." I inadvertently missed this reference in my research for my article, "Invasive aspergillosis of the hand" (J HAND SURG 7:38-42, 1981). This was brought to my attention by Dr. Anne B. Redfern and it includes a case of aspergillosis of the finger, which according to Dr. Redfern, was operated upon by Dr. Raymond Curtis. I did my best in researching the literature but sometimes Murphy's Law holds. I am happy to offer my apologies to Dr. Prystowsky et aI., and Dr. Curtis, for my oversight. Bertram Goldberg, M .D. , F.A.C.S. Colonel, MC Orthopedic Service Fitzsimons Army Medical Center Aurora, CO 80045